Learning Objectives
By the end of this section, you will be able to:
- Correlate the incidence, risk factors, signs and symptoms, diagnostic procedures, staging, current treatment, and nursing care for cervical cancer
- Distinguish the incidence, risk factors, signs and symptoms, diagnostic procedures, staging, current treatment, and nursing care for uterine cancer
- Summarize the incidence, risk factors, signs and symptoms, diagnostic procedures, staging, current treatment, and nursing care for ovarian cancer
- Critique the incidence, risk factors, signs and symptoms, diagnostic procedures, current treatment, and nursing care for vulvar and vaginal cancer
- Categorize nursing care for specific gynecologic surgeries
Prevention and early detection are key components of cancer care. Nurses play a vital role in providing education to patients regarding regular wellness checkups and screening exams. The U.S. Preventive Services Task Force (USPSTF) publishes and provides guidance for recommended screening intervals. Some of the current recommendations include such items as no regular cervical cancer screening for persons AFAB under age 21 or those over age 65 or who have undergone a hysterectomy. Other professional organizations also weigh in on these guidelines, including the American College of Obstetricians and Gynecologists (ACOG). These and other professional organizations do not always agree on the timing or efficacy of screening exams, which confuses patients and care providers (Ward, 2023) As with all medical information, nurses provide patients with the most up-to-date, evidence-based information available at the time.
Cervical Cancer
A slow-growing cancer found in the cervix is called cervical cancer (Figure 6.11). Most cervical cancer can be attributed to HPV infection. HPV strains 16 and 18 cause more than 70 percent of all cervical cancers. (CDC, 2022a). The HPV vaccine, given to preteens and persons up to the age of 45, can protect sexually active people from the cancer-causing HPV strains (CDC, 2022a).
Risk Factors
Risk factors for cervical cancer include human papillomavirus (HPV) infection, human immunodeficiency virus (HIV) positive status, and cigarette smoking. There are more than 500 different strains of the HPV virus. Strains 16 and 18 are responsible for 70 percent of cervical cancers, 90 percent of anal cancers, and 45 percent of oropharyngeal cancers (Ward, 2023).
Signs and Symptoms
Abnormal cervical cells or precancerous cells often have no symptoms and are found only with regular cervical screening exams. Occasionally, the patient will present with cervical bleeding following sex or between menstrual cycles. Pelvic pain and unusual vaginal discharge may also be warning signs of cervical cancer (CDC, 2023). The recommendations of how often screening exams should be completed have evolved. The evidence suggests that annual screening exams have not been shown to decrease mortality from cancer (Ward, 2023). The medical community has a much better understanding of the growth patterns of HPV and has adjusted the guidelines based on this understanding (ACOG, 2023a).
Diagnostic Procedures
Cervical screening and HPV DNA testing are done in most labs around the country. These two combined screening exams are referred to as co-testing. Cells are removed from the endocervical area using a brush in a procedure called a Papanicolaou test, or Pap smear. Most labs can also test for HPV infection and, if one is present, determine the strain. The results from these screening exams are used to determine an individualized approach to further testing using the 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) risk-based management consensus. The guidelines are available on the ASCCP website, and a handy app allows for simple interpretation of the recommendations (Perkins et al., 2020).
Link to Learning
Watch this animation showing the Pap test to see the steps involved.
If further testing is recommended, the patient will undergo a colposcopy and possibly a biopsy. The colposcopy allows the provider to visualize the cervical tissue under a high-powered microscope with a bright light. Using different solutions applied to the cervix to highlight abnormal areas, the provider may take biopsies to look for the depth of abnormal cells (Schuiling & Likis, 2020). The screening tests for cervical cancer are summarized in Table 6.2.
| Tests | Process |
|---|---|
Co-testing for both HPV and cervical cell changes
|
|
Medical and Surgical Management
Treatments for cervical precancer and cancer include cryotherapy (freezing) of the cells to allow for healthy cells to regenerate. Ablation with a laser may be done to remove abnormal cells. Conization of the cervix is the process of excising a cone-shaped piece of tissue to remove the full thickness of abnormal cells. The loop electrosurgical excision procedure (LEEP) allows the provider to remove a large portion of the endocervical area and cauterize at the same time. This tissue can be sent to the pathology lab for further examination (Schuiling & Likis, 2020).
Nursing Care
Nursing care for a patient undergoing a cervical diagnostic procedure such as a Pap smear includes education about the procedure and what to expect. It is helpful to show the speculum to the patient and describe the sounds made when the device is opened, as it can be startling if they are not expecting it. The patient should provide consent for the procedure and be reassured that consent can be withdrawn at any time and the examination will cease.
Patients who have undergone a colposcopy, LEEP, or biopsy should be informed that some vaginal bleeding may occur (Schuiling & Likis, 2020) A peripad can be provided with instructions on which signs and symptoms should be reported. All patients who have undergone screening or diagnostic testing should be given realistic expectations of when their results will be available and how they will receive them.
Ovarian Cancer
Ovarian cancer is an abnormal growth of cells on the ovaries that quickly multiply and can invade surrounding tissues (Figure 6.12). Ovarian cancer can be caused by a gene mutation or can occur naturally. Patients who have taken contraceptives that cause anovulation, have breast-fed, or have had multiple pregnancies are at a potentially lower risk.
Risk Factors
Risk factors for ovarian cancer include a family history of female organ cancers, especially if the person is positive for the BRCA1 and BRCA2 gene mutation. Other risk factors include:
- obesity
- nulliparity (never having been pregnant)
- infertility
- history of endometriosis
- beginning menstruation at a younger age or starting menopause at an older age than average (Ward, 2023)
Signs and Symptoms
The signs and symptoms of ovarian cancer can be vague (Ward, 2023). This often leads to a diagnosis at a later stage, which increases the morbidity and mortality of the disease (Schuiling & Likis, 2020). Unexplained weight loss and fatigue should prompt any patient to seek a medical evaluation, as these can be symptoms of cancer in the later stages. Other symptoms may include:
- increased feelings of abdominal fullness
- increased flatulence
- feeling full after eating small amounts of food
- pelvic pain
- irregular vaginal bleeding
Diagnostic Procedures
Diagnostic procedures for ovarian cancer include ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). In some cases, a positron emission tomography (PET) scan may be used to look for distant disease. The blood test, called cancer antigen 125 (CA125), is often positive in patients with ovarian cancer but can also be positive in other conditions, making the test not specific enough to use as a screening tool (Ward, 2023).
Medical Management/Treatment
Medical management is determined based on the stage of the cancer when discovered. These stages are summarized in Table 6.3. Staging is done by examining the tumor, lymph node involvement, and metastasis to other sites. The higher the stage, the more the cancer has advanced. If the cancer is found early, surgery to remove the ovaries, fallopian tubes, and uterus may be performed. Chemotherapy and radiation therapy may also be offered based on the staging of the disease (Schuiling & Likis, 2020).
| Stage | What It Means |
|---|---|
| Stage I | Cancer is confined to one or both ovaries. |
| Stage II | Cancer has spread to the uterus or other nearby organs. |
| Stage III | Cancer has spread to the lymph nodes or abdominal lining. |
| Stage IV | Cancer has spread to distant organs, such as the lungs or liver. |
Legal and Ethical Issues
Cancer during Pregnancy
Cervical and ovarian cancers are the most common cancers that occur during pregnancy (Bohlin et al., 2024). Diagnostic testing with magnetic resonance imaging (MRI) and sonogram can be used during pregnancy without harm to the fetus.
Cervical cancer treatment can be initiated after the fetal lungs have matured, and birth via cesarean section is recommended (Bohlin et al., 2024). If cancer has progressed, treatments such as chemotherapy, radiation, or hysterectomy with removal of lymph nodes are not compatible with pregnancy.
Ovarian cancer can be treated during pregnancy by removing the ovary and adnexa if the cancer has not metastasized; however, advanced ovarian cancer might necessitate chemotherapy and radiation that is contraindicated in pregnancy (Bohlin et al., 2024).
Providers must discuss staging and treatment options along with gestation of pregnancy. Patients must decide on their willingness to terminate the pregnancy, conservatively treat the cancer during pregnancy, or wait for treatment until after the birth. These decisions can be very challenging for the patient and their family. Providers and nurses must offer ethical support to the patient.
Nursing Care
Nursing care for a patient undergoing testing for ovarian cancer or treatment after diagnosis involves the use of therapeutic listening and support. Often when a patient is stressed or traumatized from hearing unwelcome news, they may repeatedly ask the same questions. Patience, caring, and understanding are some of the best tools available to the nurse.
Clinical Safety and Procedures (QSEN)
Patient-Centered Care
The diagnosis of ovarian cancer can be devastating to the patient. The nurse can provide patient-centered care when answering questions regarding the diagnosis and treatment. The nurse will approach the patient with sensitivity and respect. The nurse encourages the patient to talk about their feelings and express their concerns. Evaluating the patient’s religious and cultural beliefs can guide the nurse to gather support resources. The nurse is available to answer questions for the family and support family members.
Uterine Cancer
One of the most common gynecologic cancers, uterine cancer may originate in the lining of the uterus (called endometrial cancer) or in the muscle of the uterus, which is the rarer form called uterine sarcoma (Society of Gynecologic Oncology, 2020). Endometrial cancer accounts for approximately 12,000 deaths per year in the United States (Ward, 2023). If detected early, uterine cancer has a high survivability rate.
The risk factors of uterine cancer include prolonged exposure to unopposed estrogen. In the normal menstrual cycle, the hormone progesterone quiets the uterus, suspends the growth of the uterine lining, and allows for the sloughing of the lining (menstruation). Some circumstances that allow for unopposed estrogen are polycystic ovary syndrome (PCOS) with anovulation and HRT without the use of progesterone. Infertility and nulliparity can also increase the risk for uterine cancer (Ward, 2023).
The signs and symptoms of endometrial cancer are unusual bleeding. Bleeding after sex, between periods, or after the start of menopause are important warning signs and need to be followed up with an evaluation as soon as possible.
Diagnostic Procedures
The diagnostic procedure for endometrial cancer is a uterine biopsy, shown in Figure 6.13. Preparation of the patient is similar to that for obtaining a Pap smear. A speculum is introduced, and a thin biopsy tool is passed through the cervix into the uterus. Cells are collected from several different areas of the uterine lining and are sent to the pathology lab. After the procedure, the patient may experience cramping and light vaginal bleeding that can last up to 24 hours.
Nursing responsibilities include preparing the patient for the procedure and supporting the patient during the biopsy. The nurse may also be responsible for preparing the specimen for transport to the pathology lab. The nurse will provide the patient with instructions to take an anti-inflammatory for cramping pain and to notify the health-care provider for vaginal bleeding that soaks a pad every 1 to 2 hours, abdominal pain, and fever (Goldstein, 2023).
Treatment
Treatment for endometrial cancer includes the removal of the uterus (hysterectomy). Depending on the spread of the disease, the fallopian tubes and ovaries may also be removed. If cancer is discovered in the early stages and confined to the uterus, recovery can be complete (Ward, 2023). If cancer has progressed, chemotherapy or radiation might be necessary.
Vulvar and Vaginal Cancer
Vulvar and vaginal cancer are very rare. These cancers have been linked to the HPV infection. The most important preventive measure is to be vaccinated against HPV to avoid infection (CDC, 2022a). Other risk factors include multiple sexual partners and smoking.
The most common symptom that patients present with is persistent itching or burning of the vulva or a sore that does not heal (Figure 6.14) (Ward, 2023). It is important to educate patients on the early warning signs of gynecologic cancers and encourage them to seek prompt attention from their health-care provider for evaluation.
Signs and symptoms of vulvar or vaginal cancer include:
- itching, burning, or pain on the vulva/in the vagina
- a lump, sore, swelling, or wart-like growth
- thickened or raised patches of skin—red, white, or brown
- a mole that changes color or shape
- a lesion or sore on the vulva
- hard or swollen lymph nodes in the groin
Diagnostic Procedures
Diagnostic procedures for vulvar and vaginal cancers include a biopsy. The three types of biopsies are as follows:
- Punch biopsy—A tool is used to remove a section of the lesion to determine thickness.
- Shave biopsy—Some tissue is removed across the top of the lesion.
- Needle biopsy—A needle removes tissue from inside the lesion.
If the lesion is determined to be cancerous, the patient will be referred to a gynecologic oncologist for further evaluation and to develop a treatment plan (Society of Gynecologic Oncology, 2020).
Hysterectomy
Surgical removal of the uterus is called a hysterectomy. A hysterectomy is one of the most common surgeries performed in the United States (ACOG, 2021). Once the uterus has been removed, a patient can no longer become pregnant.
The four ways a hysterectomy can be performed include:
- through the vagina
- through the abdomen
- using laparoscopy (minimally invasive surgery) to assist in removal of the uterus
- using robot-assisted laparoscopy (in which a robot-controlled arm is used to assist the surgeon with the fine motor movements needed in the abdomen).
All these surgical options have benefits and potential risks. The health-care provider will discuss these with the patient and, using shared decision making with the patient, decide on a treatment plan.
Depending on the reason the hysterectomy is being performed, the uterus may be removed by itself, or the fallopian tubes and ovaries may be removed as well. For example, if the purpose is to remove fibroids, the ovaries and fallopian tubes may be left intact. If the reason for the hysterectomy is cancer, the ovaries and fallopian tubes may be removed. Because the ovaries secrete hormones, their removal will prompt a physiologic menopause that may require hormone replacement therapy.
Risks Associated with Hysterectomy
Surgery of any kind comes with risks. Risks specific to hysterectomy include:
- infection
- hemorrhage
- injury to the bladder
- injury to other nearby organs
- blood clots
- anesthesia complications (ACOG, 2021)
Preoperative and Postoperative Care for Hysterectomy
Preoperative care for a hysterectomy is the same as for any other surgical procedure. The patient will have baseline screening of their cardiac activity (electrocardiogram, or EKG) and complete blood counts. In some cases, presurgical antibiotics will be ordered to reduce the chance of infection. A plan for venous thromboembolism (VTE) prophylaxis will be ordered based on provider and hospital protocol.
Postoperative care will usually include a hospital stay of 1 to 3 days, depending on the type of surgery performed and the patient’s recovery. The patient will be encouraged to resume walking soon after surgery to prevent blood clots. Constipation and inability to pass urine are common concerns following a hysterectomy. A diet rich in fiber along with adequate hydration can assist with constipation. In some cases, a stool softener may be recommended. Vaginal bleeding may be present and may require the use of peripads. Vaginal rest is recommended for a minimum of 6 weeks after surgery. The patient is instructed not to place anything in the vagina during that time. The patient should be instructed not to lift heavy items until released by the surgeon to do so.
Legal and Ethical Issues
The Legacy of Henrietta Lacks and Her Contribution to Medicine
A young mother diagnosed with an aggressive form of cervical cancer made a huge contribution to medicine when her unusual cells were made into the cell line nicknamed HeLa cells.
HeLa cells, derived from Henrietta Lacks’s name, have made profound contributions to medical science and research since their collection in the early 1950s. They are considered "immortal" in that they can grow and divide endlessly in a laboratory, where other cell lines cannot. These cells have been instrumental in numerous groundbreaking discoveries, including the development of the polio vaccine, advancements in cancer research, and insights into cellular biology. HeLa cells have been pivotal in understanding cell behavior, genetic mechanisms, and the testing of pharmaceuticals. Their unique ability to continuously replicate has provided scientists with a consistent and reproducible experimental platform, accelerating progress in diverse fields. Investigators did not ask Henrietta Lack for permission to use her cells. And while the researchers who discovered the cell line's unique capabilities originally gave them away freely to other scientists, HeLa cells were later commercialized and used to drive profits. Until Lacks' family settled a lawsuit with a biotech company in 2023, her family never saw any financial benefit from the usage of her cells. Despite this ethical consideration surrounding their use, HeLa cells remain an indispensable tool in scientific exploration, shaping the landscape of modern medicine and contributing significantly to the understanding of human biology and disease.
Read this article to learn more about Henrietta Lacks and HeLa cells.