Reproductive tract melignancy- obstetrics and gynaecological nursing

OG

1. Female Genital Tract Malignancies

2. Human Female Genital System

3. Introduction Reproductive tract malignancies are an important topic in gynecology because of the high mortality, morbidity and shortening of life span in women.

4. Definition Female reproductive tract malignancies is also known as Gynecological cancers of the female genital tract that occur when abnormal cells starts dividing in an uncontrolled way. Net source

5. 1. VULVAR CANCER

6. The vulva is the external genitalia of the female reproductive tract . Vulva

7. Vulvar cancer Vulvar cancer is a cancer that starts in the external female sex organs – inner edges of the labia majora or labia minora

8. Vulvar Cancer Epidemiology 4th most common gynecologic cancer (following uterus, ovary and cervix) Comprises 5% of gynecologic malignancies Mean age at diagnosis is 65y, but is decreasing

9. Cigarette smoking Human Papilloma Virus (HPV) infection Immunosuppression Chronic vulvar conditions such as lichen sclerosus VIN/CIN Prior history of cervical cancer Causes & Risk Factor

10. Pathogenesis Two pathways of vulvar carcinogenesis: HPV infection (60%) Chronic inflammatory (vulvar dystrophy) or autoimmune processes

11. THE CLINICAL MANIFESTATIONS OF VULVAR CANCER

12. Clinical Manifestations Most patients present with a single vulvar plaque, ulcer or mass Labia major is the most common site Lesions are multifocal in 5% of cases A synchronous second malignancy is found in 22% of cases, usually CIN/cervical cancer

13. Clinical Manifestations Pruritus is the most common presenting symptom (especially if associated with vulvar dystrophy such as lichen sclerosus) Vulvar bleeding or discharge Dysuria Enlarged groin lymph node

14. Clinical Manifestations

15. Clinical Manifestations

16. Clinical Manifestations

17. Clinical Manifestations

18. Diagnosis Biopsy of gross lesions If no gross lesion present but high clinical suspicion, perform colposcopy

19. Types of Vulvar Cancer Squamous cell carcinoma SCCA (>90% of cases) Melanoma Sarcoma Basal cell carcinoma Verrucous carcinoma Adenocarcinoma (Bartholin gland)

20. Vulvar Cancer Staging (Surgical) Stage Description IA Lesion < 2 cm with < 1 mm stromal invasion, no nodal metastases IB Lesion >2 cm with >1 mm stromal invasion, no nodal metastases II Lesion any size, extension to adjacent structures, no nodal metastases III Lesion of any size with involvement of the lower urethra, vagina or anus OR groin lymph node metastases IVA Tumor invading upper urethra, bladder mucosa, rectal mucosa, pelvic bone IVB Any distant metastases, including pelvic lymph nodes

21. Treatment of SCCA Vulvar Stage Treatment IA Wide local excision (WLE) IB WRE and inguinal- femoral lymphadenectomy II WRE and inguinal- femoral lymphadenectomy III WRE and inguinal- femoral lymphadenectomy OR chemoradiation +/- surgery to resect residual disease as needed IVA chemoradiation +/- surgery to resect residual disease as needed IVB Chemotherapy

22. Treatment of SCCA Vulvar : Surgery Wide Radical Excision (WRE) : Excision of vulvar lesion down to the fascia of the urogenital diaphragm 2 cm tumor- free margin Inguinal- Femoral Lymphadenectomy : Removal of the superficial inguinal and deep femoral lymph nodes

23. Indicated if positive margins after WRE if re- excision not possible or desirable (i.e. around the clitoris or anal sphincter) Indicated if positive inguinal/pelvic nodes Radiation in combination with chemotherapy is an alternative to surgery in women with stage III/IVA disease Treatment of SCCA Vulvar : Radiation therapy

24. Treatment of SCCA Vulvar : Chemotherapy Indicated for metastatic disease (stage IVB) Platinum- based Treatment is palliative

25. Chemotherapy regimens SCCA Vulvar First- Line Combination Therapy REGIMEN DOSING Paclitaxel (Taxol) + cisplatin (Platinol; CDDP) Day 1: Paclitaxel 135mg/m 2 IV, admi over 24 hr plus Day 2: Cisplatin 50mg/m 2 IV at a rate of 1mg/min. Repeat cycle every 3 weeks for 6 cycles. Carboplatin (Paraplatin) + paclitaxel Day 1: Carboplatin AUC=5mg/mL/min administered over 1 hr, followed by paclitaxel 175mg/m 2 administered over 3 hrs. Repeat cycle every 3 weeks for 6–9 cycles or until disease progression or unacceptable toxicity

26. Chemotherapy regimens SCCA Vulvar First- Line Combination Therapy cont’d REGIMEN DOSING Cisplatin + topotecan (Hycamtin) Days 1–3: Topotecan 0.75mg/m 2 IV administered over 30 min plus Day 1: Cisplatin 50mg/m 2 IV. Repeat cycle every 3 weeks. Cisplatin + gemcitabine (Gemzar) Days 1 and 8: Cisplatin 30mg/m 2 + gemcitabine 800mg/m 2 . Repeat cycle every 4 weeks.

27. Chemotherapy regimens SCCA Vulvar First- Line Monotherapy REGIMEN DOSING Cisplatin (preferred as a single agent) Day 1: Cisplatin 50mg/m 2 . Repeat cycle every 3 weeks for a total of 6 cycles.

28. Chemotherapy regimens SCCA Vulvar Second- Line Therapy REGIMEN DOSING Bevacizumab (Avastin) Day 1: Bevacizumab 15mg/kg IV. Repeat cycle every 3 weeks. Docetaxel (Taxotere) Day 1: Docetaxel 100mg/m 2 IV, administered over 1 hr. Repeat cycle every 3 weeks

29. OTHERS TYPES OF VULVAR CANCER

30. Melanoma of the Vulva 2 nd most common type of vulvar cancer (5- 6%) Occurs more frequently in white women Mean age at diagnosis is 68y Treatment is wide local excision with 2 cm margins and sentinel lymph node biopsy

31. Melanoma of the Vulva

32. Basal Cell Carcinoma 2% of vulvar cancers Usually occur in white, postmenopausal women May be locally invasive but usually do not metastasize Slow- growing Treatment is wide local excision

33. Basal Cell Carcinoma

34. Paget Disease of the Vulva <1% of vulvar malignancies Most patients are postmenopausal and Caucasian Most common presenting symptom is pruritus Lesion is usually well demarcated slightly raised edges and a red background Treatment is wide local excision

35. Paget Disease of the Vulva

36. 2. VAGINAL CANCER

37. Vagina T he muscular passage that leads from the cervix to the vulva

38. Vaginal cancer Vaginal cancer, sometimes referred to as primary vaginal cancer . Cancer that starts in the vagina.

39. Vaginal cancer Primary vaginal cancer Secondary vaginal cancer the cancer originates in the vagina cancer spreads to the vagina from another organ Represents 2- 3% of Pelvic Cancers There are two main kinds of vaginal cancer :

40. Primary vaginal cancer Squamous cell carcinoma: Clear cell adenocarcinoma Melanoma : .

41. Secondary vaginal cancer 84% of cancers in vaginal area are secondary Cervical Uterine Colorectal Ovary

42. Causes & Risk Factor Cigarette smoking Human Papilloma Virus ( HPV 16 and 18 ) infection Immunosuppression VIN/CIN Prior history of cervical cancer Treatment for womb cancer by radiotherapy

43. Clinical Manifestations Symptoms appear , often in later stages. They can include: Painless vaginal bleeding, between periods, after menopause, or after sex Vaginal discharge (may smell or be bloody)pain during sex A lump in the vagina that you can feel A persistent itch in the vagina

44. Clinical Manifestations Advanced vaginal cancer can also cause : constipation pain when peeing swelling in the legs (oedema) persistent pelvic pain

45. Diagnosis Biopsy to look for either precancerous (VAIN) or cancerous cells Scans and x- rays to see if the cancer has spread to other parts of your body.

46. Vagina cancer Staging Stage I : Stage II : Stage III : Stage IVA : Stage IVB : Confined to Vaginal Wall Subvaginal tissue but not to pelvic sidewall Extended to pelvic sidewall Bowel or Bladder Distant metastasis

47. Treatment of vaginal cancer Surgery with Radical Hysterectomy and pelvic lymph dissection in selected stage I tumors high in Vagina All others treated with radiation with chemosensitization

48. Treatment of vaginal cancer cont’d Radiation with chemo sensitization radiotherapy concurrently with weekly intravenous Cis- platinum chemotherapy (40 mg/m2 )

49. 5 year Survival Stage I Stage II Stage III 70% 51% 33% Stage IV 17%

50. Prevention The few things known to help, though, are avoiding smoking, and getting regular smear tests to detect precancerous or cancerous cells early: VAIN VIN ; HPV CIN

51. Pap smear test

52. 3. CERVICAL CANCER

53. Cervix

54. Cervical cancer Cervical cancer begins in the cervix (the neck of the womb), which is a strong muscle that forms the passage between the womb and the vagina.

55. Cervical cancer epidemiology Approximately 570,000 cases expected worldwide each year 275,000 deaths Number one cancer killer of women worldwide With the advent of the Pap smear, the incidence of cervical cancer has declined

56. Cervical Cancer Etiology Cervical cancer is a sexually transmitted disease. HPV is the primary cause of cervical cancer. Some strains of HPV have a predilection to the genital tract and transmission is usually through sexual contact (16, 18 High Risk).

57. Cervical Cancer Risk Factors Early age of intercourse Number of sexual partners G iving birth to more than 7 children having your first child before 17yrs S moking High- risk male partner Taking the pill Having a weakened immune system

58. Pathogenesis

59. Clinical Manifestations May be silent until advanced disease develops Post- coital bleeding Foul vaginal discharge Abnormal bleedin g Unilateral leg swelling or pain Pelvic mass Pelvic pain Gross cervical lesion

60. The Stages Of Cancer Progression The pre- cancerous stage before the cells turn cancerous is called Cervical Intra-epithelial Neoplasia commonly in short called CIN

61. Clinical Manifestations cont’d

62. Diagnosis A cone or hysterectomy specimen Colposcopy Biopsy MRI, a CT or PET- CT scan, blood tests or a chest X- ray

63. Cold Cone Biopsy

64. Colposcopy Medical Test A procedure that allows doctor to look at the surface of cervix and biopsy any abnormal areas.

65. Staging Of Cervical Cancer

66. Treatment of Early Disease Conization Or Simple Hysterectomy - Micro invasive cancer Radical hysterectomy - R emoval of the uterus with its associated connective tissues, the upper vagina, and pelvic lymph nodes . Chemo radiation therapy

67. Radical hysterectomy - removal of the uterus

68. Advanced Staging Chemoradiation is the mainstay of treatment 4- 5 weeks of external radiation treats the primary tumor and adjacent tissues and lymph nodes Chemotherapy acts as a radiation sensitizer and may also control distant disease

69. Locally advanced cervical cancer regimens First- Line Therapy with Radiotherapy REGIMEN DOSING Cisplatin 40mg/m2 IV on days 1, 8, 15, 22, 29, and 36 (total dose not to exceed 70mg per week). Cisplatin + 5- FU Days 1 and 29 : 4 hrs prior to external- beam radiotherapy: Cisplatin 50mgDinfusion /m2 IV at 1mg/min with standard hydration, plus Days 2–5 , and 30–33: 5- FU 1000mg/m2 IV continuous infusion over 24 hrs (total dose 4000mg/m2 each course).

70. Locally advanced cervical cancer regimens cont’d …. First- Line Therapy with Radiotherapy REGIMEN DOSING Cisplatin + 5- FU Days 1–5 of radiotherapy: Cisplatin 75mg/m2 IV over 4 hrs followed by 5- FU 4000mg/m2 IV over 96 hrs. Repeat cycle every 3 weeks for 2 additional cycles. Cisplatin + 5- FU +hydroxyurea Days 1 and 29: Cisplatin 50mg/m2 IV followed by 4000mg/m2 5- FU over 96 hrs; hydroxyurea 2g orally twice weekly for 6 weeks.

71. Locally advanced cervical cancer regimens cont’d … First- Line Therapy with Radiotherapy REGIMEN DOSING Induction therapy Days 1, 8, 15, 22, 29 and 36: Cisplatin 40mg/m2 + gemcitabine 125mg/m2 + concurrent external- beam radiotherapy 50.4Gy in 28 Cisplatin + gemcitabine + fractions, followed by brachytherapy radiotherapy +brachytherapy 30–35Gy in 96 hrs. Adjuvant therapy Day 1: Cisplatin 50mg/m2, plus Days 1 and 8: Gemcitabine 1,000mg/m2. Repeat every 3 weeks for 2 cycles.

72. Metastatic or Recurrent Cervical Cancer Regimens Similar regimens as those used for metastatic vulvar cancer

73. Reduce the Risk R educe the risk of contracting the virus, which in turn can reduce the risk of getting cervical cancer S tart having sex when mature , and less sexual partners because more you have higher your chances are of developing cervical cancer

74. 4. UTERINE CANCER

75. Wall Of Uterus

76. Womb cancer Also known as , cancer of the uterus, uterine cancer or endometrial cancer(++) B egins in the lining or walls of the uterus.

77. Epidemiology Most common gynecologic malignancy Eighth leading cause of female mortality from cancer 97% arise from the endometrium (endometrial carcinoma) 3% arise from the mesenchymal components (sarcoma)

78. Types Of Womb Cancer Uterine sarcoma There are two main types of womb cancer: “ starts in the womb’s lining, or endometrium often caught early, and treated successfully. : S tarts in the muscle wall of the womb both less common and harder to treat. • Endometrial : 95% of womb cancers cancer

79. Sub-types Leiomyosarcoma : Cancer of the muscle wall - the most common sarcoma of the womb Papillary serous : carcinoma Around 5% of womb cancers • Clear cell carcinoma: Extremely rare, 1 to 2% of womb cancers Adenocanthomas: combine both glandular and cervical types of malignant cells

80. Two main types of womb cancer Endometrial carcinoma Uterine sarcoma

81. THE FIRST TYPE OF WOMB CANCER: ENDOMETRIAL CARCINOMA (95%)

82. Endometrial Carcinoma

83. Epidemiology Median age of diagnosis: 60 years Most common in women > age 50 years Incidence is highly dependent on age 75% of uterine cancers occur in post- menopausal women

84. Endometrial Carcinoma Risk Factors RISK FACTORS OESTROGEN OTHERS OBESITY DIABETES HYPERTENSION NPCC

85. Oestrogen Exposure EXOGENOUS HRT Tamoxifen for breast cancer ENDOGENOUS Early menarche Late menopause PCOs Obesity Functioning ovarian tumours

86. NULLIPAROUS WOMEN NULLIPAROUS WOMEN & WOMEN WITH PCOD NON OVULATION HIGH OESTROGEN ENDOMETRIAL HYPERPLASIA ENDOMETRIAL CANCER

87. RISK FACTORS NULLIPARITY PCOS EARLY MENARCHE LATE MENOPAUSE OBESITY DIABETES HYPERTENSION LYNCH 2 / HNPCC TAMOXIFEN HRT

88. Clinical Manifestations Bleeding Present in 90% of all cases 15 % of patients with postmenopausal bleeding will have endometrial cancer Other Signs/Symptoms Vaginal Discharge(80-90%) Pelvic Pain, Pressure Referred Leg Pain Change in Bowel Habits Pyometria / Hematometria

89. Diagnosis Pap Smear Only 30- 50% patients with cancer will have an abnormal result Endometrial Biopsy False negative rate of 5- 10% Trans vaginal Ultrasound Not for routine screening or diagnosis Fractional Dilation and Curettage Use in cases of cervical stenosis, patient intolerance to exam, recurrent bleeding after negative biopsy

90. Endometrial Cancer Grade The grade is based on the percentage of the solid component . Well Differentiated (Grade 1): <5% Moderately Differentiated (Grade 2): 5- 50% Poorly Differentiated (Grade 3): > 50%

91. Endometrial carcinoma type There are two major pathogenic types of endometrial carcinoma : Type I Type II

92. Type I Endometrial Carcinoma Younger / peri - menopausal women Well differentiated endometrioid Superficial myometrial invasion Infrequent lymph node metastases a ssociated with hyperplasia Better prognosis

93. Type II Endometrial Carcinoma Older/post- menopausal women Thin Poorly differentiated carcinoma Papillary Serous Clear Cell Deep myometrial invasion Frequent lymph node metastases Associated with atrophy

94. Endometrial Carcinoma Treatment Surgery is the mainstay of treatment followed by adjuvant radiation and/or chemotherapy based on stage of disease. Primary radiotherapy or hormonal therapy may be employed in patients who have contraindications to surgery.

95. Hormone Therapy Appropriate in patients that desire fertility preservation Young patient Well differentiated cancer ONLY- G1 tumors!! High dose progestins

96. Endometrial Cancer Hormonal Regimens Hormonal Regimens (for Endometrioid Only) Tamoxifen (Nolvadex) Tamoxifen 20mg orally twice daily. Medroxyprogesterone acetate (MPA) Medroxyprogesterone acetate 200mg orally once daily. Tamoxifen +medroxyprog esterone acetate Medroxyprogesterone acetate 80mg orally twice daily for 3 weeks alternating with tamoxifen 20mg orally twice daily. Repeat cycle every 3 weeks. Combination is associated with grade 4 thromboembolic events in a few patients. 1

97. Endometrial Cancer chemotherapy regimens Chemotherapy Regimens and other Treatment Regimens REGIMEN DOSING Day 1: Doxorubicin Cisplatin (Platinol; 45mg/m 2 IV + cisplatin 50mg/m 2 IV, followed by CDDP) +doxorubicin (Adria Days 2–11: Optional filgrastim mycin) (for adjuvant use) 5mcg/kg/day. Repeat cycle every 3 weeks; maximum 6 cycles. Day 1: Doxorubicin 45mg/m 2 IV + cisplatin 50mg/m 2 IV followed by Cisplatin + doxorubicin +p Day 2: Paclitaxel 160mg/m 2 3- hr IV infusion, followed by aclitaxel (Taxol) Days 3–12: Filgrastim 5mcg/kg SC. Repeat cycle every 3 weeks for max 7 cycles. Maximum BSA of 2.0 was used for calculations.

98. THE SECOND TYPE OF WOMB CANCER: UTERINE SARCOMA( 3%)

99. Uterine Sarcoma 3% of all uterine cancers 1 5 % of all deaths from uterine cancer Types Carcino sarcoma Leiomyo sarcoma Endometrial Stromal Tumours

100. Uterine Sarcoma Treatment: Surgery Stage I/II sarcomas should be treated with hysterectomy Lymphadenectomy is indicated in all sarcomas except leio myosarcoma Bilateral salpingo - ophorectomy NOT in premenopausal women

101. Uterine Sarcoma Treatment: Recurrence Isolated lesions S urgical excision Recurrent carcino sarcoma P aclitaxel , Platinum or Ifosfamide Recurrent leio myosarcoma Doxorubicin , Ifosfamide , Docetaxel and Gemcitabine

102. Uterine Sarcoma Chemotherapy regimens Chemotherapy REGIMEN DOSING Doxorubicin (Adriamycin) Day 1: 75mg/m 2 IV bolus. Repeat cycle every 31 days OR 60mg/m 2 –70mg/m 2 IV typically dosed every 3 weeks. Gemcitabine (Gemzar) +do cetaxel (Taxotere) +granulo cyte-colony-stimulating factor (G- CSF) Days 1 and 8: Gemcitabine 900mg/m 2 IV over 90 min, followed by Day 8: Docetaxel 100mg/m 2 IV over 60 min, followed by Days 9–15: G- CSF 150mcg/m 2 SC OR on Day 9 or 10: Pegfilgrastim 6mg SC. Repeat cycle every 3 weeks until disease progression or toxicity occurs. Gemcitabine Days 1, 8 and 15: Gemcitabine 1,000mg/m 2 IV. Repeat cycle every 4 weeks.

103. 5. FALLOPIAN TUBES CANCER

104. The Fallopian tubes The Fallopian tubes , also known as oviducts , uterine tubes, and salpinges are two very fine tubes leading from the ovaries into the uterus, via the utero- tubal junction

105. WHAT IS FALLOPIAN TUBE CANCER

106. Fallopian tube cancer Fallopian tube cancer begins in a woman’s fallopian tubes Adenocarcinoma sarcoma Chori sarcoma others Secondary + + +

107. Epidemiology One of the most rare malignancy of the female genital tract 0.3% of all gynecology malignancies 3.6 / million women Mean age of diagnosis 50 yrs. 2/3 menauposal 5 years survival 56%

108. Risk factors Nulliparity Chronic salpingistis Infertility 70% cases inflammatory disease (such as TB)

109. Clinical manifestations of FTC Vaginal bleeding, especially after menopause Abdominal or pelvic pain or feeling of pressure Vaginal discharge, which may be clear, white, or tinged with blood A pelvic mass or lump

110. Diagnosis of FTC Preoperative diagnosis very rare Sonography Serum ca 125

111. Staging of FTC Stage I : Confined to fallopian Stage II : Confined to pelvis Stage III: Extra pelvic disease Stage IV: Distant Metastasis

112. Treatment of FTC Surgery For early disease As an adjuvant therapy Reassessment laparotomy Chemotherapy Platinum based combination chemotherapy

113. 6. OVARIAN CANCER

114. Ovary ovary is an ovum- producing reproductive organ, in pairs they are both gonads and endocrine glands

115. WHAT IS OVARIAN CANCER

116. Ovarian cancer Ovarian Cancer is cancer that forms in the tissue of the ovary

117. Epidemiology Ovarian cancer is the second most common gynecologic cancer after uterine cancer. It causes more deaths than any other gynecologic cancer. 80 % will survive 1 year and about 50% will survive 5 years .

118. Risk factors Family history of the disease is one of the most significant risk factors The risk of ovarian cancer increases with age Rates are highest where diets tend to be high in fat . Animal fats (red meats, whole milk or cheese)

119. Types of ovarian cancer There are many different types, but the most common are three: 1. Ovarian Epithelial Carcinoma ; B egins in the cells of the surface of the ovaries.(90 %) 2. Malignant Germ Cell Tumor ; Cancer that begins in the egg cells . 3. Stromal ; Cancer that develops on the connective tissue that holds the ovary together and produces most of the female hormones.

120. Pathogenesis 1. Genetic Mutation: Inherited 5 to 10% of Ovarian Cancer Genetic Mutation: Environmental Infertility & infertility drugs Obesity in adulthood Talcum Powder Estrogen & Hormone Replacement Therapy Oncogenes and Tumor- suppressors The genes most affected in families with a history of Ovarian Cancer

121. Clinical manifestations Abdominal pressure, swelling, or bloating Urinary urgency or burning with no infection Pelvic discomfort or pain Persistent indigestion, gas, or nausea Changes in bladder and bowel habits Persistent lack of energy Low back pain Changes in menstruation.

122. Diagnosis Physical Malignancy : irregular, solid consistency, is fixed , nodular, or bilateral, is associated with ascites Ultrasound Low positive predictive value for cancer Tumor markers Epithelial: CA 125, elevated in 80% 35 U/mL is upper limit of normal Also elevated in many benign conditions

123. Stage of ovarian cancer

124. Ovarian Cancer Treatments There are many different kinds of treatments available, depends on certain factors, like: T he stage and size of the tumors A ge G eneral health Desire to have kids

125. Ovarian Cancer Treatments cont’d … Surgery Is the most common. The surgeon tries to remove as much of the tumor as possible Chemotherapy Chemo is commonly used after surgery to kills cancer cells that weren’t removed Radiation Therapy The main goal is to reduce pain symptoms Biotherapy/Immunotherapy Boosts the body’s immune system to fight the disease.

126. Ovarian cancer chemotherapy regimens Intravenous First- Line Primary Chemotherapy/Primary Adjuvant Therapy (Stage II–IV) REGIMEN DOSING Paclitaxel (Taxol) + carboplatin (Pa raplatin) Day 1: Paclitaxel 175mg/m 2 IV administered over 3 hrs + carboplatin AUC=5–7.5mg/mL/min IV administered over 1 hr. Repeat every 3 weeks for 6 cycles. Docetaxel (Taxotere) +carboplatin Day 1: Docetaxel 60–75mg/m 2 IV followed by carboplatin AUC=5–6mg/mL/min IV. Repeat every 3 weeks for 6 cycles. Dose-dense paclitaxel +carboplatin Day 1: Carboplatin AUC=6mg/mL/min IV administered over 1 hr, plus Days 1, 8, and 15: Paclitaxel 80mg/m 2 IV administered over 1 hr. Repeat every 3 weeks for 6 cycles.

127. Ovarian cancer chemotherapy regimens Intraperitoneal First- Line Therapy for Advanced Disease REGIMEN DOSING Paclitaxel + cisplatin (Platinol; CDDP) Day 1: Paclitaxel 135mg/m 2 continuous IV infusion over 24 hrs, followed by Day 2: Cisplatin 75– 100mg/m 2 IP, followed by Day 8: Paclitaxel 60mg/m 2 IP (maximum body surface area 2m 2 ). Repeat every 3 weeks for 6 cycles.

128. NURSES RESPONSIBILITIES • Teach women the importance of having routine screenings for cancer of the reproductive system. (pap smear, and pelvic exam) • Teach women about the risk factors of the reproductive system. • Teach women about menopause signs and symptoms after bilateral oophorectomy. • Teach women about hormone replacement therapy and the side effects

129. NURSES RESPONSIBILITIES Cond….. • Manage client's pain related to chemotherapy • Monitor for infection. • Teach client how to prevent DVTs after surgery , i.e . frequent changes in positions, leg exercises to promote circulation. • Explain the need for increased intake of fruits, vegetables , and whole grains. Also, a decreased fat intake of <30% of calories.