Cervical Cancer

Cervical Cancer Case Study and Care Plan Cervical Cancer The following represents an outline for a plan of care, including information intended to educate the patient about what she can expect given her recent diagnosis of cervical cancer at the age of 45. The good news is that a cervical cancer diagnosis is no longer a death sentence. Cervical cancer in women is common and afflicts close to 530,000 women worldwide each year (Colombo et al., 2012).

Importantly, human papillomavirus (HPV) infections are believed to be the most important causative agent and this virus is detected in 99% of all cervical tumors. Accordingly, the expected protection rate conferred by the HPV vaccine is around 70%. Of the three categories of cervical cancer recognized by the World Health Organization (WHO), squamous cell carcinoma is by far the most common, representing 70-80% of all cervical cancers (Colombo et al., 2013). Other types of cervical cancer include glandular (adenocarcinoma), neuroendocrine, undifferentiated, or mixed.

The type of cancer is important because it impacts prognosis and plan of care, in addition to how advanced the disease is (stage), tumor size, patient age, and patient health (NCI, 2013). Once cervical cancer has been diagnosed the first step is to stage the cancer (NCI, 2013). Of primary concern is whether the tumor is localized within the cervix, involves the whole cervix, or has spread to the surrounding tissues and lymph nodes.

The Bethesda System for cervical cytology classification helps initiate this process by providing terminology standards for specimen quality, type of cervical cancer, and grade of lesion (Davey, 2003). A number of imaging tools are also available to help determine the extent of cancer spread within the cervix, surrounding tissue, and the rest of the body if metastatic disease is suspected (NCI, 2013). Stage 0 is used to categorize microscopic tumors confined to the innermost lining of the cervix (NCI, 2013).

Stage I tumors are also confined to the cervix, but are bigger in size and will have invaded the cervix tissue. The main difference between stage IA1, IA2, IB1, and IB2 is size, with the last stage in this sequence representing tumors large enough to be seen without a microscope and involving the entire cervix. Stage II tumors have spread beyond the cervix into surrounding tissues.

Stage IIA cervical tumors have involved the upper two thirds of the vagina, but not the uterus or surrounding tissues, while stage IIB has involved the tissues around the uterus. The difference between stage IIA1 and IIA2 is also mainly size. Stage III represents tumors that have involved most of the vagina, pelvic wall, and/or compromised kidney function. The difference between stages IIIA and IIIB is the degree to which the tumor has spread, with stage IIIB representing pelvic involvement to the extent that ureter function is compromised.

If the bladder and/or rectum are also involved then the cancer is classified as stage IVA, but if the cancer has spread to other regions of the body far from the pelvic region then it is considered stage IVB. Treatment Plan As discussed above, staging is the first step towards developing a treatment plan. Either a computed tomography (CT) or magnetic resonance imaging (MRI) will likely be performed to initially determine how big the tumor is and whether it has metastisized (Small et al., 2012).

Additional imaging tests may need to be performed if the disease has spread beyond the cervix, including positron emission tomography (PET) or a combination of PET and CT. Such studies will be needed to stage the disease, determine whether surgery is appropriate, and guide surgeons should surgery be indicated (Querleu and Morrow, 2008). PET and CT have also been useful for detecting involvement of the lymph system. Once the stage of the disease has been determined the choice of therapy can be made.

Surgery (typically total hysterectomy) or definitive radiation therapy (RT) are appropriate interventions for early stage cervical cancer (up to stage IB1). Removal of involved lymph nodes will also be performed when necessary in early stage cervical cancer. A single clinical trial revealed equivalent survival results whether surgery or RT was used; however, surgery has a better chance of preserving sexual function and avoids the risk of radiation-induced tumors. Women suffering from stage 0 to IB1 cervical cancer, without lymph involvement, may choose radical hysterectomy over a total hysterectomy (Querleu and Morrow, 2008).

This surgery is designed to remove the cervix entirely while preserving ureter function. Women with stage IB to IIA cervical cancer may be treated using chemoradiotherapy (Small et al., 2012). Chemoradiotherapy combines RT with chemotherapy to reduce the risk of recurrent metastatic disease. The most common drug in use is weekly cisplatin, but other drugs have proven effective, including fluorouracil (5-FU), gemcitabine, and taxol. Combinations of chemotherapeutic drugs have been used with some success, but toxicity becomes a real concern.

Once the tumor has grown to the point it is visible without a microscope (IB2 and above) treatment options center on radiation therapy (Small et al., 2012). A clinical trial comparing two different radiation therapy approaches for IB to IIA patients revealed that pelvic RT, combined with chemotherapy, provided significant protection against recurrence and improved overall survival. The most effective chemoradiotherapy combination was cisplatin with 5-FU concurrent with pelvic RT.

For patients with stage IB cervical cancer, no measurable benefit has been found for adjuvant hysterectomy (Small et al., 2012); however, patients with more advanced stages of disease will typically undergo chemoradiotherapy followed by total hysterectomy (NCI, 2013). Long-Term Management RT has been shown to carry the greatest risk of long-term morbidity compared to surgery alone (Wolfson et al., 2012). The primary complications were lower extremity edema, urinary problems, and gastrointenstinal toxicity 5 years after treatment.

In contrast, patients that had undergone a hysterectomy experienced sexual problems, including decreased sensation, less lubrication, smaller vagina, pain during intercourse, and sexual dissatisfaction. Surgery patients also reported bladder problems, constipation, and limb swelling; however, most of these symptoms had returned to baseline after two years. Current recommendation for vaginal stenosis is the use of vaginal dilators post-surgery, twice a week for 15-20 minutes indefinitely, even if the patient is sexually active. Concerns about ovarian preservation, however, are minimal given the age of the patient considered here.

There is always a risk of recurrent disease. Current recommendations are to conduct cervical cytology, physical examination, and a female hormone panel every three to six months for at least the first five years following treatment, then annually if the patient remains disease-free.