NR602 Ground Rounds Week 6 Cervical Cancer Richards_Tneshia.pptx

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Unformatted text preview: Cervical Cancer Chamberlain University NR602 February 2020 Tneshia L. Richards Pathophysiology of Cervical Cancer Cervical Intraepithelial Neoplasia (CIN) Changes in the cervical epithelium that is precancerous and can progress into an invasive malignancy of the cervix Most of these changes occur at the squamocolumnar junction (SCJ) and affect the squamous epithelial cells (80-90% of cervical cancers) or columnar epithelial cells (10-20% of cervical cancers) These result in squamous cell carcinoma and adenocarcinoma Human Papillomavirus (HPV) More than 200 strands of this virus have been identified ranging from low to high risk for cervical cancer High Risk Strains 16 and 18 are responsible for 70% of all cervical cancers High risk strains produce viral proteins that disable tumor suppression genes causing an increased proliferation of abnormal cells (Hollier, 2018) (Rerucha et al., 2018) Image retrieved from pinterest.com Pathophysiology of Cervical Cancer Epidemiology of Cervical Cancer In 2018, an estimated 569,847 cases of cervical cancer were diagnosed. Of these diagnosed, 311,365 deaths occurred worldwide due to this malignancy In the United States Third most common gynecologic cancer in the United States (US) Approximately 12,000 new cases diagnosed annually More than 4,000 deaths annually Hispanic and black women are affected more often Most are commonly diagnosed after the age of 30 50-64% of cancers occur in women who were rarely or never screened (Cahen et al., 2019) (Hollier, 2018) (Wipperman, Neil, & Williams, 2018) Image retrieved from unr.edu Risk Factors of Cervical Cancer Image retrieved from prepareformedicalexams.blogspot.com Younger than 18 years of age at first intercourse Current or previous infection with HPV Weakened immune system from HIV, AIDS, or another illness that weakens the body’s ability to destroy abnormal cells Cigarette smoking increases one’s risk by 2 to 3 times of a nonsmoker’s risk Multiple sexual partners Diethylstilbestrol (DES) exposure (a synthetic estrogen) in utero increases the risk for clear cell adenocarcinoma Long-term oral contraceptive use (>5 years) Parity of three or more births Family history of cervical cancer Herpes simplex virus-2 (HSV-2) and chlamydia (Hollier, 2018) (Wipperman, Neil, & Williams, 2018) Clinical Assessment Findings of Cervical Cancer Patient Complaints In early stages, the patient is often asymptomatic Presence of abnormal uterine bleeding in 80-90% of patients Vaginal discharge that is watery or purulent and malodorous Dyspareunia with postcoital bleeding Hematuria Pelvic and back pain Constipation Bladder outlet obstruction Swelling of legs due to lymphatic or vascular obstruction Image retrieved from healthella.com (Hollier, 2018) Clinical Assessment Findings of Cervical Cancer Physical Assessment Findings In the early stages, the cervix may appear normal Cervical erosion, ulcerations, or a bleeding mass Decreased mobility or hardening of the cervix Irregular, cauliflower-like growth on the cervix Rectal exam may reveal bleeding from tumor compression Fistula may be present on exam (Hollier, 2018) Image retrieved from healthella.com Differential Diagnoses of Cervical Cancer Severe Cervicitis Image retrieved from ufhealth.org Asymptomatic, mucopurulent vaginal discharge, itching, burning, urinary symptoms, postcoital bleeding, cervical edema and inflammation Leukorrhea in vaginal fluid indicating a chlamydial or gonococcal infection Nabothian Cyst Image retrieved from medlineplus .gov Common benign tumor-like lesion o the cervix that is usually asymptomatic Translucent or opaque, whitish to yellow in color Ablation or excision to remedy Endometrial Carcinoma Postmenopausal vaginal bleeding (Abnormal), abnormal vaginal discharge, and cramps Pap smear testing shows endometrial cells that need to be biopsied (DeCherney et al., 2014) (Hollier, 2018) Image retrieved from slideshare.net Diagnostic Studies to Confirm Cervical Cancer Diagnosis Pap Test May include HPV DNA typing May include STD Testing Colposcopy Endocervical Biopsy Loop Electrosurgical Excision Procedure (LEEP) and/or Cold Knife Cone Biopsy Cystoscopy or Proctoscopy for advanced or large tumors CBC, CMP, renal and hepatic function tests Image retrieved from news.sphp.com MRI, CT, Chest X-Ray and PET Scan for staging which is based on the International Federation of Gynecology and Obstetrics (FIGO) staging system (ACOG, 2016) (Hollier, 2018) (Wipperman et al., 2018) Prevention of Cervical Cancer PRIMARY PREVENTION HPV Vaccination (Gardasil-9) for Patients 9-26 years of age Smoking Cessation Use of Barrier Contraceptives Patient Education about Preventive Measures and Vaccination SECONDARY PREVENTION Cervical Cytology or Pap Test that is based on Age and Risk Factors HPV DNA Testing Colposcopy Image retrieved from alabamapublichealth.gov (ACOG, 2016) (Hollier, 2018) (Rerucha et al., 2018) ACOG 2016 Cervical Cancer Screening Guidelines Image retrieved from conehealth.com (ACOG, 2016) (Hollier, 2018) (Kim, Burger, Regan, & Sy, 2018) (Rerucha et al., 2018) Abnormal Pap Test Types of Abnormal Pap Test Results Atypical squamous cells of undetermined significance (ASC-US) Low-grade squamous intraepithelial lesion (LSIL) High-grade squamous intraepithelial lesion (HSIL) Atypical squamous cells, cannot exclude HSIL (ASC-H) Atypical glandular cells (AGC) Further Testing Required This testing is based on the patients age and initial Pap Test Results Image retrieved from DeCherney et al., 2014 (ACOG, 2016) (DeCherney et al., 2014) ASC-US Atypical Squamous Cell of Undetermined Significance Management of ASC-US for Women by Age (ASC-US is the MOST COMMON Pap Test result) Women 21-24 years old Preferred: Repeat Pap Test in 12 Months Acceptable: Reflex HPV Test Women 25-29 years old Preferred: Reflex HPV Test Acceptable: Repeat Pap Test in 12 Months Women 30 years old and older HPV Negative: Repeat co-testing in 3 years HPV Positive: Colposcopy Image retrieved from cdc.gov (ACOG, 2016) (Kim et al., 2018) Treatment of Cervical Cancer Non-Pharmacologic Treatment Pharmacologic Treatment Treatment for cervical cancer is based on the staging of the cancer Chemotherapy Drugs-These are the first-line combination therapies that may be used: Precancer Lesion Therapy Cisplatin (Platinol) Cryosurgery Carboplatin (Rx) Loop Electrosurgical Excision Procedure (LEEP) Gemcitabine (Gemzar) Cone Biopsy Topotecan (Hycamtin) Laser Ablation Bevacizumab (Avastin) Cervical Cancer Therapy Total or Radical Hysterectomy Radiation Therapy Pelvic Lymph Node Dissection Paclitaxel (Taxol) Image retrieved from curemedi calglobe.c om (Hollier, 2018) (Wipperman et al., 2018) Patient & Family Education Related to Cervical Cancer Get the HPV Vaccination (Gardasil-9) for Patients 9-26 years of age (It’s so Important) Smoking Cessation Use of Barrier Contraceptives Get Pap Testing as Recommended If your patient is a Cervical Cancer Survivor: Be aware of local recurrence: vaginal discharge, vaginal bleeding, dyspareunia, pelvic pain Sexual Health: Vaginal lubrication, pelvic floor therapy, psychotherapy Long-Term Effects of Treatment: Cystitis, proctitis, ovarian failure, chronic pelvic pain Counseling regarding future pregnancy risk and possible inability to conceive (Hollier, 2018) (Wipperman et al., 2018) Optimal Outcomes for Cervical Cancer Detailed History and complete physical exam including: Speculum exam with bimanual Pelvic exam Pap Test based on Current Guidelines Follow-up Every 3 months for first 2 years Every 6 months for 3-5 years Image retrieved from thatcompany.com Annually after 5 years (Hollier, 2018) (Wipperman et al., 2018) Questions for Discussion What is the difference between a high risk and a low risk strain of the Human Papillomavirus (HPV)? What is the recommended guidelines for receiving the HPV Vaccinations by the CDC? Why is it important to receive the vaccination for HPV prior to sexual activity and if a person is sexually active, can they still receive the vaccination? References ACOG: American College of Obstetricians and Gynecologists, (2016). Abnormal cervical cancer screening test results. Retrieved from Cahen, P. A., Jhingran, A., Oaknin, and Denny, L. (2019). Cervical Cancer. The Lancet, 393(10167), 169-82. Retrieved from . DeCherney, A., Nathan, L., Laufer, N., & Roman, A. (2014). Current diagnosis & treatment Obstetrics & Gynecology (11th ed.). New York, NY: McGraw-Hill. Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.) Lafayette, LA: Advanced Practice Education Associates. Kim, J. J., Burger, E. A., Regan, C., & Sy, S. (2018). Screening for cervical cancer in primary care: A decision analysis for the US Preventive Services Task Force. Journal of the American Medical Association, 320(7), 706-714. Retrieved from Rerucha, C. M., Caro, R. J., & Wheeler, V. L. (2018). Cervical cancer screening. American Family Physician, 97(7), 441-448. Retrieved from Wipperman, J., Neil, T., and Williams, T. (2018). Cervical cancer: Evaluation and management. American Family Physician, 97(7), 449-454. Retrieved from ...
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