1. 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:
© 2008 by Lippincott Williams & Wilkins. All world rights reserved.

2. 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

3. Picturing Cervical Cancer

4. 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

5. Risk Factors Exposure to human papillomavirus (HPV) Sexual activity
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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Pap Results and Care For ASC-US: For AGC-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

12. 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

13. The FIGO Staging System

14. 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

15. 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

16. Picturing Total Hysterectomy

17. 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

18. 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