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Cancer of the cervix
Cancer of the Cervix Leslee J. Thompson
ANCER OF THE cervix is considereda preventable diseasebecauseof its long preinvaC sive state, the availability of cytology screening programs, and effective treatment of preinvasive lesions. The exact incidence of invasive cervical cancer is not known, but the best data indicate a rate of 10 to 12 casesper 100,000 population per year.’ It is estimated that in 1990, there will be approximately 6,000 deaths from cervical cancer and 13,500 new cases diagnosed in the United States,*and 400 deathsand 1,500 new casesdiagnosed in 1989 in Canada.3Worldwide, carcinoma of the cervix is the secondleading causeof cancer deaths among women aged 25 to 39 years. In developed countries, it ranks 12th among all cancers in women over the age of 40. Rates of cervical cancerare highest in Brazil (83.2 per 100,000population) and lowest in Israel (four per 100,000 population).4 The low rate among Jewish women gave rise to the now-discounted theory that male circumcision may be a protective factor. A more plausible explanation of this low rate is the adherence to the strict religious tradition of monogamy, a pattern that is also evident in other religious sects, such as the Amish and SeventhDay Adventists. Cervical cancer is almost nonexistent in a truly celibate population. The developmentof cervical cancer seemsto be related to an exposure of the cervix to multiple injuries and insults, although the causeof cervical cancer is unknown. Scientists suspect, however, that there is a connection between sexual intercourseand cervical cancer, mainly due to the number of partners. Data now also suggestthat wives and lovers of men who have multiple partners, no matter how monogamousthe women may be, are
From the Division of Gynaecologic Oncology, University of Toronto and Toronto Bayview Regional Cancer Centre, Ontario, Canda. Leslee J. Thompson, RN, MScN: Nursing Director, Toronto Bayview Regional Cancer Centre, and Assistant Professor of Nursing, University of Toronto. Address reprint requests to Leslee J. Thompson, RN, MScN, Toronto Bayview Regional Cancer Centre, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5. 0 1990 W.B. Saunders Company. 0749-2081BOlO603-0003$05.00i0
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at increased risk of cervical cancer.5Y6Other factors that increase risk are low socioeconomic statu~,~‘*first coitus at an early age,6vgand cigarette smoking.i”,‘l There is no correlation with frequency of intercourse.’ A number of possible etiologic agentsfor cervical cancer have received attention over the past few years, including Trichomonas species,sperm, and smegma,but all of thesehave been cleared of suspicion. Herpes simplex virus type II also received a great deal of attention, although there is great controversy about whether the virus is carcinogenic, oncogenic, or merely associatedas a passenger with a multiplicity of sexual partners.’ Recently, attention has shifted to the human papillomavirus (HPV) infection of the cervix as a link to etiology. Of the 50 different strains of sexually transmitted HPV, HPV 16 is found in approximately 50% of invasive squamous cell cancers, and HPV 18 in approximately 20%. ‘**13 Human papillomavirus strains 16 and 18 are also found in many casesof adenocarcinomaof the cervix.i4 Severalstrategiesexist to help reduce the risk of HPV and preinvasive cancer of the cervix. These include public education about links between sexual behavior, smoking, and the development of cervical cancer, as well as about the importance of regular Papanicolaou(Pap) smears.Celibacy, monogamy, and the use of barrier-type contraception can also help reduce these risks.” PRESENTATION AND CLINICAL MANIFESTATIONS
Since the introduction of the Pap smearin 1941, and colposcopy in 1925, it is easy to diagnoseand treat cervical malignancies in their preinvasive state; consequently, mortality from cervical cancer has decreasedby 50%. Preinvasive carcinoma of the cervix (cervical intraepithelial neoplasia[CIN]) is usually detected on the Pap smear and is confirmed by colposcopic examination and biopsy. The woman with preinvasive disease is usually asymptomatic;however, the colposcopic examination may reveal abnormal blood vessels, irregular surface contour, and color tone changes on the Seminars in Oncology Nursing, Vol6,
No 3 (August), 1990: pp 190-197
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OF THE CERVIX
cervix. I6 The first symptom of early invasive cancer of the cervix is a thin, watery, blood-tinged discharge that may or may not be noticed by the patient. The classic symptom pattern begins with painless, intermittent bleeding, which appearsinitially as only postcoital spotting; as the lesion enlarges, the bleeding episodes become more frequent, heavier, and of longer duration. Late symptoms that indicate advanceddiseaseinclude flank or leg pain, dysuria, or rectal bleeding. All of these symptomsare indicative of metastasisto the pelvic side wall, ureters, lymph nodes, or sciatic nerve roots. Persistent leg edema as a result of lymphatic and venous blockage, massive hemorrhage, and developmentof uremia may all occur as preterminal events in patients with manifestations of metastaticprimary or recurrent disease.r There are three categoriesof gross cervical lesions: endophytic, exophytic, and excavating or ulcerative lesions. Endophytic lesions are located within the endocervical canal and, becausethere is no visible tumor or ulceration, the cervix appears normal but feels hard to the touch. Exophytic lesions are the most common, and are cauliflowerlike, fungating lesions that are friable and bleed quite easily. These lesions can sometimesdistend the cervix and the endocervical canal to create what is commonly referred to as a “barrel-shaped lesion.“’ Ulcerative lesions usually appear as necrotic lesions that erode and replacethe cervix and upper vagina. These lesions bleed easily and are often associatedwith local infection and purulent discharge. DIAGNOSIS, EVALUATION,
AND STAGING
A definitive diagnosis of cervical cancer requires the histologic evaluation of a tissue sample, and the selection of treatment dependson the histologic diagnosisand clinical stage,which are usually determined by an examination under anesthesia. Diagnostic aids to the staging processinclude the physical examination, cystoscopy, sigmoidoscopy, routine chestx-rays, intravenouspyelogram, and lymphangiography. The International Federationof Gynecology and Obstetrics(FIGO) stagingclassification of cervical cancerwas revised in 1986and is outlined in Table 1. Ninety percent of the cervical cancersare squamous cell carcinomas. Five to eight percent are adenocarcinomas, which are considered a high-
Table 1. IWO Stage 0 Stage I IA IA1 IA2
I9 Stage II
IIA II9 Stage Ill
IIIA IIIB
Stage IV IVA IVB Reprinted
Staging
Cluslfieetion
for Cervical
Cenwr
Carcinoma in situ, intraepithelial carcinoma Carcinoma confined to the cervix (extension to the corpus should be avoided) Preclinical carcinomas of the cervix (diagnosed only by microscopy) Minimal microscopically evident stromal invasion Lesions detected microscopically that can be measured, showing no more than a 5-mm depth of invasion when taken from the base of the epithelium, and no more than 7 mm of horizontal spread Lesions of greater dimensions than stage IA2, whether seen clinically or not Involvement of the vagina, but not the lower third, or infiltration of the parametria, but not out to the side wall Involvement of the vagina, but no evidence of parametrial involvement Infiltration of the parametria but not out to the side wall Involvement of the lower third of the vagina or extension to the pelvic side wail; all cases with hydronephrosis or nonfunctioning kidney unless known to be from another cause Involvement of the lower third of the vagina, but not out to the pelvic side wall Involvement of one or both parametria out to the side wall or hydronephrosis or nonfunctioning kidney Extension beyond the true pelvis Involvement of the mucosa of the bladder or rectum Distant metastasis with permission.’
risk category asthey are more difficult to detecton Pap smears. This is because of the high falsenegative rate of Pap smearsand the fact that lesions are often subepithelial. Consequently, most adenocarcinomasare diagnosedat a later stage. Carcinoma of the cervix in association with pregnancy is a relatively uncommon problem with an approximate incidence of 1 per 1,240 pregnancies.l7 Approximately 20% of patients with invasive cervical cancer are asymptomatic, which demonstratesthe importance of inspecting the cervix and doing Pap smears in all patients at the initial antenatal visit. l7 Even when pregnant patients present with symptoms of abnormal vaginal bleeding, the diagnosis of cervical cancer is often delayed becausethe symptoms can be readily attributed to threatenedabortion or placenta previa. Any patient with vaginal bleeding, persistent discharge, or postcoital bleeding in which placenta previa has been ruled out should have a repeat speculumexamination to allow adequatevisualization of the cervix and a repeat Pap smear.r7
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LESLEE J. THOMPSON
Mechanisms of Spread and Prognostic Indicators
There are three primary mechanismsof spread of cervical cancer: direct extension and lymphatic and hematogenousspread. With direct extension, the lesion originates on the cervix and spreadsto surrounding cervical tissue, into the parametrium, and to the bladder or rectum. Spreadto the lymph nodes occurs in a fairly orderly pattern: from the paracervical lymph node chain, to the obturator (internal iliac) and external iliac lymph nodes, to the common iliacs, and then to paraaortic nodes. Late metastatic spread is to the mediastinal and supraclavicular nodes. Hematogenous spread is not very common, except in advanced disease. Sites of this type of metastasisinclude lung, liver, and bones. Some have suggestedthat this type of spreadis more common with adenocarcinomas.’ Prognostic indicators of cervical cancer include stage of disease, depth of stromal invasion, and vascular spaceinvolvement. Each of these indicators correlates with the incidence of pelvic lymph node metastasis. Survival is dependent on this lymph node status. Patients with negative nodes will have approximately a 90% survival rate at 5 years, and those with positive nodeshave a 20% to 60% 5-year survival rate, depending on the number and size of nodes involved, as well as the location of the nodes.’ In a recent Gynecologic Oncology Group (GOG) study, patients’ age, lymphatic spaceinvolvement, depth of invasion, and parametrial involvement were all identified as independent risk factors for pelvic lymph node metastasis.l8 TREATMENT
MODALITIES
Early diagnosis and treatmentis the cornerstone of survival for this disease.DiSaia and Creasman’ emphasize that “the gradient of percentage curability from early invasive cancer to late and grossly invasive diseaseis such a steep one that even a moderatereduction in tumor size could not fail to create a substantial improvement in curability. ” The key principle of treatmentfor carcinoma of the cervix is to treat the local disease and any potential lymph node spread. The two main treatment modalities are surgery and radiation therapy. Surgical treatment is limited to patients with early disease,stagesI and IIa, and for selectedpatients with recurrent disease.Radiation therapy is often considered the primary treatment
since it can be used to treat all stagesof the disease. Both radiation therapy and surgery, however, offer the same cure rates for patients with stage Ib and IIa disease:a 5-year survival rate of approximately 85% with either modality.” There are noted advantages in using surgery over radiation therapy in the treatment of early cancer of the cervix, particularly for the younger patient. These advantages include shorter treatment time, preservation of ovarian function in young women, higher patient acceptance,and limited sexual morbidity. l9 The more concretethinking patient often perceives the surgical “removal” of the tumor as more effective in getting the tumor “out” of her body. Additional reasons for the selection of surgery over radiation therapy include previous irradiation therapy for other disease, concomitant inflammatory bowel disease or pelvic inflammatory disease, patient preference, and pregnancy.’ Managementof CIN diagnosedin pregnancy is conservative. Patients can deliver vaginally unless other obstetrical complications are present, and the patient is reassessedwith colposcopy and biopsy 6 weekspostpartum. If microinvasive diseaseis discovered in pregnancy, a shallow conization of this areais necessaryto rule out invasive carcinoma of the cervix. For casesof early invasive cervical cancer diagnosed in the first trimester, traditional treatment (surgery or radiation) is indicated, and the pregnancy aborted.17In the second trimester, the therapy approachis similar, except that it may be necessaryto evacuatethe uterus by hysterotomy first. In the third trimester (after 26 to 28 weeks’ gestation), arriving at treatment decisions may present a dilemma. Any decision to delay therapy should be made only after thorough deliberation with the patient and her family. With the expert neonatal care available today, good fetal salvage should be expected after 32 weeks’ gestation. Treatment of the patient would consist of cesarean section followed by either surgery or radiation treatment. In general, prognosis for all stagesof cervical cancer in pregnant patients is similar to that for nonpregnant patients with cervical cancer.17 Surgical Therapy
The radical nature of surgical treatment for patients with invasive cancer of the cervix depends
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OF THE CERVIX
on the risk of pelvic nodemetastasisand the size of the tumor. There has been considerableconfusion and debatein the literature about which parameters should be used to define patients who are not at risk for lymph node metastasesor recurrence, as they may be treated with less radical therapeutic approaches.This group of patients includes those with microscopic disease,the most common definition of which is that originally put forward by the Society of Gynecologic Oncologists in 1974: “A microscopic lesion is one in which neoplastic epithelium invades the stroma to a depth of s3 mm beneath the basement membrane and in which lymphatic or blood vascular involvement is not demonstrated.’ ’ I9 Patients with a stageIal or Ia lesion (ie, l- to 3-mm invasion) have an incidence of less than 1% for pelvic lymph node metastasis.” Thesepatients can be treatedby conization or simple hysterectomy. Simple hysterectomy involves the removal of the uterus and the cervix, with no intervening parametrial tissue or lymph node removal. Patients selectedfor simple hysterectomy over cone biopsy usually have completed their childbearing function, or have associatedpelvic pathology such as fibroids or irregular bleeding. Radical hysterectomy is the surgical treatment of choice for patients who have diseaseconfined to the cervix and when the probability of lymph node metastasisis greater than 5%. i9 The procedureinvolves the removal of the uterus, cervix, upper one third of the vagina, and all or part of the parametrium on each side, as well as bilateral lymph node dissection of the external and internal iliac nodes. The ovaries are conservedin young women sincemetastasisto the ovaries are rare. Acute complications of radical hysterectomy that occur in 62% of casesinclude formation of ureterovaginal or vesicovaginal fistulae, pulmonary embolus, and small-bowel obstruction. l9 The most common acute complication is febrile morbidity; however, the use of wide-spectrumantibiotics has prevented this problem. Less than 5% of patients experience wound infections and this low incidence is most likely linked with the provision of good nursing care. Subacutecomplications of the radical hysterectomy include postoperative bladder dysfunction and the formation of lymphocysts. The degree of bladder dysfunction is related to the width and extent of surgical dissections.Typically, bladder volume is decreasedand tilling pressureincreasedfor
the first few days after surgery. The patient may also have a reduced sensitivity to filling and an inability to initiate voiding. This may be related to the fact that the parasympatheticnerve supply to the bladder is often severed during surgery and, until this repairs itself, bladder function is impaired. The patient must be able to void on her own with a residual volume of 75 mL before catheter drainageis discontinued. Bladder hypotonia or even atony can occur as a chronic complication of the radical hysterectomy in approximately 3% of patients.I9 Information regarding hydration and hygiene with prolonged catheterization, as well as a strict bladder training regimen combined with intermittent self-catheterization, may manage this problem. Radiation Therapy
Radiation therapy is the most common treatment modality for cervical cancer. Cure rates for early stagediseaseare equal to those obtained with surgery (ie, approximately 80%). l9 Cure rates for advanced diseasetreated with radiation are 60% for stageII, 30% for stageIII, and only 10% for stage IV.19 Postoperative radiation may improve survival for patients with more than three positive nodes.*’ The use of radiation in this subsetof patients is quite controversial, however, as no prospective randomized study has been done to document the effectiveness of such an approach. In addition, the rates of bowel and urinary tract complications may increase with postoperative radiation therapy.I9 Radiation therapy for all stagesof cancer of the cervix consistsof a combination of external beams to treat regional nodes and part of the central disease and intracavitary brachytherapy to treat the rest of the central tumor. Approximately 4,500 cGy is given in daily fractions for a period of 5 weeks, followed by an intracavitary application of cesium using a tandem source to deliver approximately4,MKl cGy internally. Interstitial therapymay be considered with carcinoma of the cervical stump or with advancedcancer of the cervix when accurateplacementof conventionalintracavitary applicatorsis not possiblebecauseof tumor obstruction or vaginal contracture. ’ Long-term prospective studies are not yet available to substantiate this approach. Use of extended-field radiation has evolved in an effort to salvagethose patients with para-aortic lymph node spread. A safe, yet effec-
194
tive, dosagelevel for this approach has yet to be substantiated. Becausemany of the patients considered for this treatment have advanced disease that has limited responseto any treatment, the true value of this approach is unclear.1 Complications of radiation can be classified as early (acute) or delayed effects. Acute complications are often related to the effects of ionizing radiation on the epithelium of the bowel and bladder. Symptomsinclude cramping, diarrhea, tenesmus, dysuria, and, occasionally, bleeding from the bowel or rectum. A diet low in lactose, glucose, and protein may help treat bowel symptoms, and the addition of antispasmodicagentsmay be helpful for both bowel and bladder problems. A week of rest from radiation therapy may be required if symptoms are severe. Late complications are relatively rare (8% to lo%), but may include bowel obstruction, fistula formation, and perforation.lg The rate of complications increases when higher doses of radiation are used and may occur up to several years after the completion of radiation treatment. Radiation necrosis and fistula formation are often mistaken for recurrent disease,and patients may die of these complications unless treated aggressively. Accurate diagnosis of the causeof the fistula with subsequentconsideration for surgical repair or bypass is necessary for cure or palliation. Small-bowel fistulae after radiation therapy rarely heal spontaneously, even with the patient receiving total parenteral nutrition. Once recurrent diseaseis ruled out, an aggressive approach with fluid replacement, nasogastricsuction, and wound care is initiated. This is sometimesfollowed by a resection or isolation of the affected portion of bowel. Urinary diversion may be required for patients with vesicovaginal fistulae, which are the most common of the chronic urinary tract complications. Ureteral strictures, which are often a sign of recurrent disease,may also occur from radiation fibrosis and, if radiation is the cause,ureteral stentsmay be inserted. Nursing management of radiation therapy complications. Nursing care of the patient with se-
vere complications of radiation therapy is indeed challenging. Managementof rectovaginal or vesicovaginal fistulae as a result of radiation is a serious problem and requires careful planning and creative nursing interventions. Comprehensivereviews of the care and rehabilitation of the patient with an ostomy and fistulae are available else-
LESLEE J. THOMPSON
where.*l’** Strategies to prevent vaginal stenosis as a result of radiation therapy are also important. Irradiation-induced fistulae develop most often in patients with compromised capillary perfusion to the pelvis from hypertension, atherosclerosis, diabetes, and obesity.23 Rectovaginal fistulae are usually diagnosed when the patient complains of passinggas or dischargewith a fecal odor through the vagina. Urinary incontinence may be suggestive of a urinary fistula. The diagnosisis confirmed by placing a tampon into the vagina and injecting methylene blue into the suspectedcommunicating organ. The tampon packing is removed after 10 to 15 minutes and assessedfor staining. Prevention of skin breakdown, odor control, nutritional support, and psychosocialcare are the foci of nursing care for patients who have a fistula. Creative methods for containing drainage often have to be devised and adaptedto individual needs (eg, use of gauze or absorption dressings, pouching techniques, or a vaginal bell drainage system). Controlling the offensive odors associatedwith fistulae is a nursing priority. An essentialpart of odor control is good hygiene: dressings must be changedfrequently, soiled materialsremoved from the patient’s room promptly, and tubes, catheters, and drainagecollectors cleansedregularly. Special items, such as charcoal-impregnated dressings, skin cleansers,and air deodorizers, have been developed for the express purpose of dealing with these types of odors and may have some effect. Pouchesmay be usedto contain odor, and a closed security pouch can be left in place for several days if drainage is pungent, yet of minimal amount. To ensure the most comprehensive support for patients with gynecologic fistulae, an enterostomal therapist should be consulted, and the need for additional psychological support servicesassessed. A complication of radiation therapy that may be preventedthrough effective nursing intervention is vaginal stenosis. The vagina will undergo some predictable changes following radiation therapy. As a result of direct trauma to the vaginal epithelium, decreasedvascular engorgementand reduced vaginal lubrication, dyspareunia, and significant sexual disruption can occur.24 Sore spots or even ulcers may form in the initial treatmentperiod, and these may take months to heal after radiation is completed. As the natural scarring processof vaginal tissue begins, the vagina becomesfibrous and tough, losing its ability to stretch during sexual excitement and intercourse.*’
CANCER
OF THE CERVIX
Dilatation regimens following radiation therapy vary depending on the treatment center. It is important, however, that the dilators are “fitted” to the individual patient and that the woman is instructedto use a generousamount of water-soluble lubricant so that the dilator can be inserted and held in place comfortably. Continued psychological support and reinforcement of proper technique are important. Patients are generally instructed to use the dilator regularly (ie, 10 to 15 minutes a day, two to three times per week), for a period of at least 2 years, as this is when the permanent degreeof tissue scarring seemsto declare itself. If patients have not been using the dilator or having intercourse during this 2-year period, severe or permanent vaginal stenosis can occur. In some cases,surgical reconstruction of the vagina is possible, although there is a further risk of rectovaginal fistula formation with this procedure. Chemotherapy
Despite the progress of modem chemotherapy, this treatmentmodality has limited use in the managementof primary or recurrent cancer of the cervix. Most cancers of the cervix (95%) are of the squamouscell type, and thesetypes of tumors are less responsiveto chemotherapy.For patients who have been previously radiated, drug absorption is compromised with the decreasedtumor vascularity, and myelosuppressiveeffects of the chemotherapy are exaggerated.Pelvic intraarterial infusions of chemotherapyfor patients with recurrent diseasehave been usedwith limited success,since pulmonary toxicity and catheter-relatedcomplications were significanLz6 One of the more promising agentsfor treatment of advancedcervical cancer has been cisplatin.*’ The GGG has studied the efficacy of this agenton patients with advancedor recurrent diseasewhereby a 50% responserate was observed, although only 15% of this group had long-term remission.’ However, investigative trials using 5-fluorouracil or cisplatin chemotherapy along with radiation treatmenthave recently shown encouraging results in patients with advancedprimary disease.28,29Clinical trials are continuing to evaluate the effectivenessof newer drugs such as ifosfamide and tax01in the treatment of advanced cervical cancer.30*3’There is no evidence to show that cervical cancer is sensitive to hormonal therapy.
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Recurrent or Persistent Disease
Approximately 35% of patients with invasive carcinomawill have recurrent or persistentdisease following therapy.’ Most patients with recurrent diseasepresent with symptoms within 2 years of primary treatment;hence, an intensive follow-up is critical. Becauseof the changesin the cervix following radiation, a punch or needle biopsy is essential for histologic confirmation of suspectedrecurrent disease.The clinical signs and symptoms of recurrent diseaseoutlined in Table 2 are subtle and varied. The prognosis for patients with recurrent or persistentdiseasedependson the extent and location of the disease. When the diseaseis centrally localized with no evidence of lymph node metastases,a radical yet curative surgical intervention (pelvic exenteration) may be considered. For patients presenting with a triad of symptoms, including unilateral leg edema, sciatic pain, and ureteral obstruction, palliative symptom management is required, as this is a classic hallmark of extensive unresectabledisease. Management of patients with recurrent or advanced disease is difficult and challenging. As mentioned earlier, the role of chemotherapy has not been rewarding, and patients with recurrence are often treated symptomatically with analgesics and palliative support. Unilateral or bilateral obstructive uropathy can be treated with urinary diversion or percutaneousnephrostomies.These can be temporarily lifesaving but ethically difficult because patients will suffer unpleasant side effects from the diseaseas well as from efforts to palliate it. Although a once-attractive option, studies indicatethat there is a limited role for urinary diversion in patients with recurrent cancer of the cervix. 32In thesesituations, neither quantity nor quality of survival time is affected in a positive way. The placement of permanent ureteral stents has also been consideredfor patients with unresectablerecurrent disease, yet a similar ethical dilemma is present.
Table 2. Signs and Symptoms
of Recurrent
Cwvicrl
Unexplained weight loss Unilateral leg edema Pelvic and/or thigh/buttock pain Serosanguinous vaginal discharge Left-sided supraclavicular node enlargement Progressive ureteral obstruction Cough, hemoptysis, and/or chest pain Adapted
with permission.’
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LESLEE J. THOMPSON
Without decompression,the patient will die of uremia; however, with decompression, the patient may still encounter problems of pain and bleeding becausethe diseaseis progressing. Chronic pain associatedwith disease progression is often quite difficult to manageeffectively. Combinations of antitumor therapy, different classes of analgesics, and behavioral approaches must all be considered. When palliative therapy is of little use or brings further debilitation, psychological interventions may provide some comfort and, secondarily, they may prevent or treat pain sequelae, such as sleep disturbances, reduced appetite, and depression. Total Pelvic Exenteration
Total pelvic exenteration is used only with curative intent for selectpatients who have a localized recurrenceof cervical carcinoma with no evidence of lymphatic involvement. The degreeof radicality used in this operation depends on the extent of diseaseand, hence, a total, anterior, or posterior exenterationmay be performed. Total exenteration involves the removal of all pelvic viscera, including the rectosigmoid and bladder. Occasionally, an anterior exenteration, which preservesthe rectum, or a posterior exenteration, which preserves the bladder, can be performed. After an extensive physical and psychological work-up, surgery is performed in three phases. The first phase is the intraoperative assessmentof diseaseand sampling of pelvic and para-aortic nodes. These nodes are subjectedto immediate frozen section analysis and the results determine whether or not the operation will continue. There have been virtually no survivors after pelvic exenteration of patients who had positive nodes.’ The second “destructive” surgical phase involves the removal of pelvic viscera and other structuresdepending on the patient’s individual situation. The creation of a urinary diversion, colostomy, and neovagina are part of the third “reconstructive’ ’ phase of the exenteration. Urinary diversions may be made with ileal segments, transverse colon, or sigmoid colon con-
duits. Complications tend to be less if the conduits are constructed with unirradiated portions of bowel. Vaginal reconstruction must take place at the time of exenterativesurgery; again, a variety of techniquesare available. Most popular are the sigmoid vaginostomy and the myocutaneousgracilis graft approach. Reports of amnion grafts are encouraging, as this technique is easy to perform, takes minimal time at surgery, and sexual outcomes are positive. 33 Researchdocumenting sexual outcomesand patient satisfaction with the various approaches to vaginal reconstruction are limited; however, comprehensive reviews of the issuesinvolved in sexual rehabilitation for patients undergoing vaginal reconstruction are available.34 Caring for the patient undergoing pelvic exenteration is a tremendous nursing challenge. The need for extensive preoperative counseling and teaching cannot be underestimated,as this is often the key to a successful recovery. Postoperative managementrequires astute assessmentskills to monitor fluid and electrolyte balance, meticulous wound care, and intensive psychological support. A collaborative team approach to patient care is essential if the complex teaching and counseling needsfor thesepatients are to be met. An intensive follow-up plan is often required to facilitate rehabilitation.35 CONCLUSIONS
Caring for the patient with carcinoma of the cervix gives rise to somespecial nursing challengesin the areasof diseaseprevention and early detection, active treatment, and palliative care. The majority of patients are able to enjoy a full survival period following their diagnosis, others must live with the often-distressing long-term effects of their radiation or surgical treatments, and still others succumb to death from disseminateddisease.It is important to understand the physical as well as the psychological processesof recovery from this gynecologic cancer so that the ultimate challenge of the health care team can be met: helping patients live as well as possible until they die.36
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5. Berman ML, Ballon SC, Berek IS, et al: Carcinoma of the uterine cervix, in Haskel CM (ed): CancerTreatment. Philadelphia, PA, Saunders, 1985, pp 429-442 6. La Vecchia C, Franceschi S, DeCarli A, et al: Sexual factors, venereal diseasesand the risk of intraepithelial and invasive cervical neoplasia. Cancer 58:935-941, 1986 7. ThomasDB: An epidemiologic study of carcinomain situ and squamousdysplasia of the uterine cervix. Am J Epidemiol 98:10-28, 1973 8. Lombard HL, Potter EA: Epidemiological aspectsof cancer of the cervix. Cancer 3:%0-968, 1950 9. Gottardi G, Gritti P, Marzi MM, et al: Colposcopic fmdings in virgin and sexually active teenagers. Obstet Gynecol 63:613-615, 1984 10. GreenbergE, Vessey M, McPhersonK, et al: Cigarette smoking and cancer of the uterine cervix. Br .I Cancer42:359369, 1980 11. SassonM, Halley NJ, Hoffman D: Cigarette smoking and neoplasiaof the uterine cervix: Smoke constituentsin cervical mucous. N Engl J Med 312:315-319, 1985 12. Jeffery J: Human papilloma virus and lower genital tract dysplasia: Driver or passenger?Sot Obstet Gynecol Can July/ A@-14, 1988 13. zur HausenH, ScheiderA: The role of papillomaviruses in human anogenital cancer, in Howley P, JabzmamrNP (eds): The Papillomaviruses. New York, NY, Plenum, 1985,pp 245249 14. Smotkin D, Berek JS, Fu YS, et al: Human papillomavirus deoxyribonucleic acid in adenocarcinomaand adenosquamous carcinomaof the uterine cervix. Obstet Gynecol 68:241244, 1986 15. Lovejoy NC: Precancerouslesions of the cervix: Personal risk factors. Cancer Nurs 10:2-14, 1987 16. Stafl A: Understanding colposcopic patterns and their clinical significance. Contemp OB/GYN 21:85-104, 1983 17. Hacker NF, Berek JS, Lagase LD, et al: Carcinoma of the cervix associatedwith pregnancy. Obstet Gynecol 59:735746, 1982 18. Delgado G, Bundy BN, Fowler WC: A prospective surgical pathological study of stage I squamouscarcinomaof the cervix: A gynecologic oncology group study. Gynecol Oncol 35:314-320, 1989. 19. Hatch KD: Cervical cancer, in Berek JS, Hacker NF (eds): Practical Gynecologic Oncology. Baltimore, MD, Williams & Wilkens, 1989, pp 241-283 20. Morrow P: Panel report: Is pelvic irradiation beneficial in the post-operative managementof stage Ib squamouscell carcinomaof the cervix with pelvic node metastasestreatedby radical hysterectomy and pelvic lymphadenectomy?Gynecol Oncol 10:105-110, 1980 21. JacksonBS, Broadwell DC (eds): The Osotomy: Colo-
rectal, Urinary and Gynecologic Surgery. Semin Oncol Nurs 2~227-293,1986 22. Smith DB: Rehabilitation of the cancer patient with an ostomy, in Gunn A (ed): Cancer Rehabilitation. New York, NY, Raven, 1984, pp 101-120 23. Boarini JH, Bryant RA, Irrang SJ: Fistula management. Semin Oncol Nurs 2:287-292, 1986 24. Andersen BL, Tumquist DC: Psychological issues, in Berek J, Hacker N (eds):Practical Gynecologic Oncology. Baltimore, MD, Williams & Wilkens, 1989, pp 631-660 25. Shover L: Sexuality and cancer: For the Woman Who Has Cancer and Her Partner. Atlanta, GA, American Cancer Society, 1988 26. Morrow CP, DiSaia PJ, Mangan CF, et al: Continuous pelvic arterial infusion with bleomycin for squamouscarcinoma of the cervix recurrent after irradiation therapy. Cancer Treat Rep 61:1403, 1977 27. StehmanFB, Ballon SC, LagasseLD, et al: Cisplatinum in advanced gynecologic malignancy. Gynecol Oncol 7:349, 1979 28. Thomas GM, Dembo AJ, Black B, et al: Concurrent radiation and chemotherapyfor carcinoma of the cervix recurrent after radical surgery. Gynecol Oncol 27:254-260, 1987 29. ThomasG, Dembo A, Fyles A, et al: Concurrentchemo radiation in advancedcervical cancer. Gynecol Oncol (in press) 30. Buxton El, Blackledge G, Mould JJ, et al: The role of ifosfamide in cervical cancer. Semin Oncol 1660-67. 1989 (suppl3) 31. McGuire WP, Ball H: A Phase II Trial of Taxol in Patients With Advanced Cervical Carcinoma. Philadelphia, PA, Gynecologic Oncology Group, 19% 32. Baker VV, Dudzinski MR, Fowler WC, et al: Percutaneousnephrostomyin gynecologic oncology. Am 1 Obstet Gynecol 149:772-774,1984 33. DePetrillo AD, Thompson LJ: Use of the amnion graft for vaginal reconstructionin gynecologic oncology. Proceedings of the Western Association of Gynecologic Oncologists, San Francisco, CA, 1989 (abstr) 34. DePetrillo AD, Thompson LJ: Sexual rehabilitation in gynaecologic oncology, in Greer BE, Berek JS (eds): Gynecologic Oncology: Treatment Rationale and Techniques. New York, NY, Elsevier (in press) 35. Lamont J, DePetrillo AD, SargentEl: Psychosexualrehabilitation and exenterative surgery. Gynecol Oncol 6:236242, 1978 36. Thompson LJ, Andersen BL, DePetrillo AD: Psychological processesof recovery from gynaecologic cancer, m Coppleson M, Monaghan J, Morrow P, Tattersall M (eds): Gynecologic Oncology. Edinburgh, UK, Churchill Livingstone (in press)
ANCER OF THE cervix is considereda preventable diseasebecauseof its long preinvaC sive state, the availability of cytology screening programs, and effective treatment of preinvasive lesions. The exact incidence of invasive cervical cancer is not known, but the best data indicate a rate of 10 to 12 casesper 100,000 population per year.’ It is estimated that in 1990, there will be approximately 6,000 deaths from cervical cancer and 13,500 new cases diagnosed in the United States,*and 400 deathsand 1,500 new casesdiagnosed in 1989 in Canada.3Worldwide, carcinoma of the cervix is the secondleading causeof cancer deaths among women aged 25 to 39 years. In developed countries, it ranks 12th among all cancers in women over the age of 40. Rates of cervical cancerare highest in Brazil (83.2 per 100,000population) and lowest in Israel (four per 100,000 population).4 The low rate among Jewish women gave rise to the now-discounted theory that male circumcision may be a protective factor. A more plausible explanation of this low rate is the adherence to the strict religious tradition of monogamy, a pattern that is also evident in other religious sects, such as the Amish and SeventhDay Adventists. Cervical cancer is almost nonexistent in a truly celibate population. The developmentof cervical cancer seemsto be related to an exposure of the cervix to multiple injuries and insults, although the causeof cervical cancer is unknown. Scientists suspect, however, that there is a connection between sexual intercourseand cervical cancer, mainly due to the number of partners. Data now also suggestthat wives and lovers of men who have multiple partners, no matter how monogamousthe women may be, are
From the Division of Gynaecologic Oncology, University of Toronto and Toronto Bayview Regional Cancer Centre, Ontario, Canda. Leslee J. Thompson, RN, MScN: Nursing Director, Toronto Bayview Regional Cancer Centre, and Assistant Professor of Nursing, University of Toronto. Address reprint requests to Leslee J. Thompson, RN, MScN, Toronto Bayview Regional Cancer Centre, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5. 0 1990 W.B. Saunders Company. 0749-2081BOlO603-0003$05.00i0
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at increased risk of cervical cancer.5Y6Other factors that increase risk are low socioeconomic statu~,~‘*first coitus at an early age,6vgand cigarette smoking.i”,‘l There is no correlation with frequency of intercourse.’ A number of possible etiologic agentsfor cervical cancer have received attention over the past few years, including Trichomonas species,sperm, and smegma,but all of thesehave been cleared of suspicion. Herpes simplex virus type II also received a great deal of attention, although there is great controversy about whether the virus is carcinogenic, oncogenic, or merely associatedas a passenger with a multiplicity of sexual partners.’ Recently, attention has shifted to the human papillomavirus (HPV) infection of the cervix as a link to etiology. Of the 50 different strains of sexually transmitted HPV, HPV 16 is found in approximately 50% of invasive squamous cell cancers, and HPV 18 in approximately 20%. ‘**13 Human papillomavirus strains 16 and 18 are also found in many casesof adenocarcinomaof the cervix.i4 Severalstrategiesexist to help reduce the risk of HPV and preinvasive cancer of the cervix. These include public education about links between sexual behavior, smoking, and the development of cervical cancer, as well as about the importance of regular Papanicolaou(Pap) smears.Celibacy, monogamy, and the use of barrier-type contraception can also help reduce these risks.” PRESENTATION AND CLINICAL MANIFESTATIONS
Since the introduction of the Pap smearin 1941, and colposcopy in 1925, it is easy to diagnoseand treat cervical malignancies in their preinvasive state; consequently, mortality from cervical cancer has decreasedby 50%. Preinvasive carcinoma of the cervix (cervical intraepithelial neoplasia[CIN]) is usually detected on the Pap smear and is confirmed by colposcopic examination and biopsy. The woman with preinvasive disease is usually asymptomatic;however, the colposcopic examination may reveal abnormal blood vessels, irregular surface contour, and color tone changes on the Seminars in Oncology Nursing, Vol6,
No 3 (August), 1990: pp 190-197
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OF THE CERVIX
cervix. I6 The first symptom of early invasive cancer of the cervix is a thin, watery, blood-tinged discharge that may or may not be noticed by the patient. The classic symptom pattern begins with painless, intermittent bleeding, which appearsinitially as only postcoital spotting; as the lesion enlarges, the bleeding episodes become more frequent, heavier, and of longer duration. Late symptoms that indicate advanceddiseaseinclude flank or leg pain, dysuria, or rectal bleeding. All of these symptomsare indicative of metastasisto the pelvic side wall, ureters, lymph nodes, or sciatic nerve roots. Persistent leg edema as a result of lymphatic and venous blockage, massive hemorrhage, and developmentof uremia may all occur as preterminal events in patients with manifestations of metastaticprimary or recurrent disease.r There are three categoriesof gross cervical lesions: endophytic, exophytic, and excavating or ulcerative lesions. Endophytic lesions are located within the endocervical canal and, becausethere is no visible tumor or ulceration, the cervix appears normal but feels hard to the touch. Exophytic lesions are the most common, and are cauliflowerlike, fungating lesions that are friable and bleed quite easily. These lesions can sometimesdistend the cervix and the endocervical canal to create what is commonly referred to as a “barrel-shaped lesion.“’ Ulcerative lesions usually appear as necrotic lesions that erode and replacethe cervix and upper vagina. These lesions bleed easily and are often associatedwith local infection and purulent discharge. DIAGNOSIS, EVALUATION,
AND STAGING
A definitive diagnosis of cervical cancer requires the histologic evaluation of a tissue sample, and the selection of treatment dependson the histologic diagnosisand clinical stage,which are usually determined by an examination under anesthesia. Diagnostic aids to the staging processinclude the physical examination, cystoscopy, sigmoidoscopy, routine chestx-rays, intravenouspyelogram, and lymphangiography. The International Federationof Gynecology and Obstetrics(FIGO) stagingclassification of cervical cancerwas revised in 1986and is outlined in Table 1. Ninety percent of the cervical cancersare squamous cell carcinomas. Five to eight percent are adenocarcinomas, which are considered a high-
Table 1. IWO Stage 0 Stage I IA IA1 IA2
I9 Stage II
IIA II9 Stage Ill
IIIA IIIB
Stage IV IVA IVB Reprinted
Staging
Cluslfieetion
for Cervical
Cenwr
Carcinoma in situ, intraepithelial carcinoma Carcinoma confined to the cervix (extension to the corpus should be avoided) Preclinical carcinomas of the cervix (diagnosed only by microscopy) Minimal microscopically evident stromal invasion Lesions detected microscopically that can be measured, showing no more than a 5-mm depth of invasion when taken from the base of the epithelium, and no more than 7 mm of horizontal spread Lesions of greater dimensions than stage IA2, whether seen clinically or not Involvement of the vagina, but not the lower third, or infiltration of the parametria, but not out to the side wall Involvement of the vagina, but no evidence of parametrial involvement Infiltration of the parametria but not out to the side wall Involvement of the lower third of the vagina or extension to the pelvic side wail; all cases with hydronephrosis or nonfunctioning kidney unless known to be from another cause Involvement of the lower third of the vagina, but not out to the pelvic side wall Involvement of one or both parametria out to the side wall or hydronephrosis or nonfunctioning kidney Extension beyond the true pelvis Involvement of the mucosa of the bladder or rectum Distant metastasis with permission.’
risk category asthey are more difficult to detecton Pap smears. This is because of the high falsenegative rate of Pap smearsand the fact that lesions are often subepithelial. Consequently, most adenocarcinomasare diagnosedat a later stage. Carcinoma of the cervix in association with pregnancy is a relatively uncommon problem with an approximate incidence of 1 per 1,240 pregnancies.l7 Approximately 20% of patients with invasive cervical cancer are asymptomatic, which demonstratesthe importance of inspecting the cervix and doing Pap smears in all patients at the initial antenatal visit. l7 Even when pregnant patients present with symptoms of abnormal vaginal bleeding, the diagnosis of cervical cancer is often delayed becausethe symptoms can be readily attributed to threatenedabortion or placenta previa. Any patient with vaginal bleeding, persistent discharge, or postcoital bleeding in which placenta previa has been ruled out should have a repeat speculumexamination to allow adequatevisualization of the cervix and a repeat Pap smear.r7
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Mechanisms of Spread and Prognostic Indicators
There are three primary mechanismsof spread of cervical cancer: direct extension and lymphatic and hematogenousspread. With direct extension, the lesion originates on the cervix and spreadsto surrounding cervical tissue, into the parametrium, and to the bladder or rectum. Spreadto the lymph nodes occurs in a fairly orderly pattern: from the paracervical lymph node chain, to the obturator (internal iliac) and external iliac lymph nodes, to the common iliacs, and then to paraaortic nodes. Late metastatic spread is to the mediastinal and supraclavicular nodes. Hematogenous spread is not very common, except in advanced disease. Sites of this type of metastasisinclude lung, liver, and bones. Some have suggestedthat this type of spreadis more common with adenocarcinomas.’ Prognostic indicators of cervical cancer include stage of disease, depth of stromal invasion, and vascular spaceinvolvement. Each of these indicators correlates with the incidence of pelvic lymph node metastasis. Survival is dependent on this lymph node status. Patients with negative nodes will have approximately a 90% survival rate at 5 years, and those with positive nodeshave a 20% to 60% 5-year survival rate, depending on the number and size of nodes involved, as well as the location of the nodes.’ In a recent Gynecologic Oncology Group (GOG) study, patients’ age, lymphatic spaceinvolvement, depth of invasion, and parametrial involvement were all identified as independent risk factors for pelvic lymph node metastasis.l8 TREATMENT
MODALITIES
Early diagnosis and treatmentis the cornerstone of survival for this disease.DiSaia and Creasman’ emphasize that “the gradient of percentage curability from early invasive cancer to late and grossly invasive diseaseis such a steep one that even a moderatereduction in tumor size could not fail to create a substantial improvement in curability. ” The key principle of treatmentfor carcinoma of the cervix is to treat the local disease and any potential lymph node spread. The two main treatment modalities are surgery and radiation therapy. Surgical treatment is limited to patients with early disease,stagesI and IIa, and for selectedpatients with recurrent disease.Radiation therapy is often considered the primary treatment
since it can be used to treat all stagesof the disease. Both radiation therapy and surgery, however, offer the same cure rates for patients with stage Ib and IIa disease:a 5-year survival rate of approximately 85% with either modality.” There are noted advantages in using surgery over radiation therapy in the treatment of early cancer of the cervix, particularly for the younger patient. These advantages include shorter treatment time, preservation of ovarian function in young women, higher patient acceptance,and limited sexual morbidity. l9 The more concretethinking patient often perceives the surgical “removal” of the tumor as more effective in getting the tumor “out” of her body. Additional reasons for the selection of surgery over radiation therapy include previous irradiation therapy for other disease, concomitant inflammatory bowel disease or pelvic inflammatory disease, patient preference, and pregnancy.’ Managementof CIN diagnosedin pregnancy is conservative. Patients can deliver vaginally unless other obstetrical complications are present, and the patient is reassessedwith colposcopy and biopsy 6 weekspostpartum. If microinvasive diseaseis discovered in pregnancy, a shallow conization of this areais necessaryto rule out invasive carcinoma of the cervix. For casesof early invasive cervical cancer diagnosed in the first trimester, traditional treatment (surgery or radiation) is indicated, and the pregnancy aborted.17In the second trimester, the therapy approachis similar, except that it may be necessaryto evacuatethe uterus by hysterotomy first. In the third trimester (after 26 to 28 weeks’ gestation), arriving at treatment decisions may present a dilemma. Any decision to delay therapy should be made only after thorough deliberation with the patient and her family. With the expert neonatal care available today, good fetal salvage should be expected after 32 weeks’ gestation. Treatment of the patient would consist of cesarean section followed by either surgery or radiation treatment. In general, prognosis for all stagesof cervical cancer in pregnant patients is similar to that for nonpregnant patients with cervical cancer.17 Surgical Therapy
The radical nature of surgical treatment for patients with invasive cancer of the cervix depends
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on the risk of pelvic nodemetastasisand the size of the tumor. There has been considerableconfusion and debatein the literature about which parameters should be used to define patients who are not at risk for lymph node metastasesor recurrence, as they may be treated with less radical therapeutic approaches.This group of patients includes those with microscopic disease,the most common definition of which is that originally put forward by the Society of Gynecologic Oncologists in 1974: “A microscopic lesion is one in which neoplastic epithelium invades the stroma to a depth of s3 mm beneath the basement membrane and in which lymphatic or blood vascular involvement is not demonstrated.’ ’ I9 Patients with a stageIal or Ia lesion (ie, l- to 3-mm invasion) have an incidence of less than 1% for pelvic lymph node metastasis.” Thesepatients can be treatedby conization or simple hysterectomy. Simple hysterectomy involves the removal of the uterus and the cervix, with no intervening parametrial tissue or lymph node removal. Patients selectedfor simple hysterectomy over cone biopsy usually have completed their childbearing function, or have associatedpelvic pathology such as fibroids or irregular bleeding. Radical hysterectomy is the surgical treatment of choice for patients who have diseaseconfined to the cervix and when the probability of lymph node metastasisis greater than 5%. i9 The procedureinvolves the removal of the uterus, cervix, upper one third of the vagina, and all or part of the parametrium on each side, as well as bilateral lymph node dissection of the external and internal iliac nodes. The ovaries are conservedin young women sincemetastasisto the ovaries are rare. Acute complications of radical hysterectomy that occur in 62% of casesinclude formation of ureterovaginal or vesicovaginal fistulae, pulmonary embolus, and small-bowel obstruction. l9 The most common acute complication is febrile morbidity; however, the use of wide-spectrumantibiotics has prevented this problem. Less than 5% of patients experience wound infections and this low incidence is most likely linked with the provision of good nursing care. Subacutecomplications of the radical hysterectomy include postoperative bladder dysfunction and the formation of lymphocysts. The degree of bladder dysfunction is related to the width and extent of surgical dissections.Typically, bladder volume is decreasedand tilling pressureincreasedfor
the first few days after surgery. The patient may also have a reduced sensitivity to filling and an inability to initiate voiding. This may be related to the fact that the parasympatheticnerve supply to the bladder is often severed during surgery and, until this repairs itself, bladder function is impaired. The patient must be able to void on her own with a residual volume of 75 mL before catheter drainageis discontinued. Bladder hypotonia or even atony can occur as a chronic complication of the radical hysterectomy in approximately 3% of patients.I9 Information regarding hydration and hygiene with prolonged catheterization, as well as a strict bladder training regimen combined with intermittent self-catheterization, may manage this problem. Radiation Therapy
Radiation therapy is the most common treatment modality for cervical cancer. Cure rates for early stagediseaseare equal to those obtained with surgery (ie, approximately 80%). l9 Cure rates for advanced diseasetreated with radiation are 60% for stageII, 30% for stageIII, and only 10% for stage IV.19 Postoperative radiation may improve survival for patients with more than three positive nodes.*’ The use of radiation in this subsetof patients is quite controversial, however, as no prospective randomized study has been done to document the effectiveness of such an approach. In addition, the rates of bowel and urinary tract complications may increase with postoperative radiation therapy.I9 Radiation therapy for all stagesof cancer of the cervix consistsof a combination of external beams to treat regional nodes and part of the central disease and intracavitary brachytherapy to treat the rest of the central tumor. Approximately 4,500 cGy is given in daily fractions for a period of 5 weeks, followed by an intracavitary application of cesium using a tandem source to deliver approximately4,MKl cGy internally. Interstitial therapymay be considered with carcinoma of the cervical stump or with advancedcancer of the cervix when accurateplacementof conventionalintracavitary applicatorsis not possiblebecauseof tumor obstruction or vaginal contracture. ’ Long-term prospective studies are not yet available to substantiate this approach. Use of extended-field radiation has evolved in an effort to salvagethose patients with para-aortic lymph node spread. A safe, yet effec-
194
tive, dosagelevel for this approach has yet to be substantiated. Becausemany of the patients considered for this treatment have advanced disease that has limited responseto any treatment, the true value of this approach is unclear.1 Complications of radiation can be classified as early (acute) or delayed effects. Acute complications are often related to the effects of ionizing radiation on the epithelium of the bowel and bladder. Symptomsinclude cramping, diarrhea, tenesmus, dysuria, and, occasionally, bleeding from the bowel or rectum. A diet low in lactose, glucose, and protein may help treat bowel symptoms, and the addition of antispasmodicagentsmay be helpful for both bowel and bladder problems. A week of rest from radiation therapy may be required if symptoms are severe. Late complications are relatively rare (8% to lo%), but may include bowel obstruction, fistula formation, and perforation.lg The rate of complications increases when higher doses of radiation are used and may occur up to several years after the completion of radiation treatment. Radiation necrosis and fistula formation are often mistaken for recurrent disease,and patients may die of these complications unless treated aggressively. Accurate diagnosis of the causeof the fistula with subsequentconsideration for surgical repair or bypass is necessary for cure or palliation. Small-bowel fistulae after radiation therapy rarely heal spontaneously, even with the patient receiving total parenteral nutrition. Once recurrent diseaseis ruled out, an aggressive approach with fluid replacement, nasogastricsuction, and wound care is initiated. This is sometimesfollowed by a resection or isolation of the affected portion of bowel. Urinary diversion may be required for patients with vesicovaginal fistulae, which are the most common of the chronic urinary tract complications. Ureteral strictures, which are often a sign of recurrent disease,may also occur from radiation fibrosis and, if radiation is the cause,ureteral stentsmay be inserted. Nursing management of radiation therapy complications. Nursing care of the patient with se-
vere complications of radiation therapy is indeed challenging. Managementof rectovaginal or vesicovaginal fistulae as a result of radiation is a serious problem and requires careful planning and creative nursing interventions. Comprehensivereviews of the care and rehabilitation of the patient with an ostomy and fistulae are available else-
LESLEE J. THOMPSON
where.*l’** Strategies to prevent vaginal stenosis as a result of radiation therapy are also important. Irradiation-induced fistulae develop most often in patients with compromised capillary perfusion to the pelvis from hypertension, atherosclerosis, diabetes, and obesity.23 Rectovaginal fistulae are usually diagnosed when the patient complains of passinggas or dischargewith a fecal odor through the vagina. Urinary incontinence may be suggestive of a urinary fistula. The diagnosisis confirmed by placing a tampon into the vagina and injecting methylene blue into the suspectedcommunicating organ. The tampon packing is removed after 10 to 15 minutes and assessedfor staining. Prevention of skin breakdown, odor control, nutritional support, and psychosocialcare are the foci of nursing care for patients who have a fistula. Creative methods for containing drainage often have to be devised and adaptedto individual needs (eg, use of gauze or absorption dressings, pouching techniques, or a vaginal bell drainage system). Controlling the offensive odors associatedwith fistulae is a nursing priority. An essentialpart of odor control is good hygiene: dressings must be changedfrequently, soiled materialsremoved from the patient’s room promptly, and tubes, catheters, and drainagecollectors cleansedregularly. Special items, such as charcoal-impregnated dressings, skin cleansers,and air deodorizers, have been developed for the express purpose of dealing with these types of odors and may have some effect. Pouchesmay be usedto contain odor, and a closed security pouch can be left in place for several days if drainage is pungent, yet of minimal amount. To ensure the most comprehensive support for patients with gynecologic fistulae, an enterostomal therapist should be consulted, and the need for additional psychological support servicesassessed. A complication of radiation therapy that may be preventedthrough effective nursing intervention is vaginal stenosis. The vagina will undergo some predictable changes following radiation therapy. As a result of direct trauma to the vaginal epithelium, decreasedvascular engorgementand reduced vaginal lubrication, dyspareunia, and significant sexual disruption can occur.24 Sore spots or even ulcers may form in the initial treatmentperiod, and these may take months to heal after radiation is completed. As the natural scarring processof vaginal tissue begins, the vagina becomesfibrous and tough, losing its ability to stretch during sexual excitement and intercourse.*’
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OF THE CERVIX
Dilatation regimens following radiation therapy vary depending on the treatment center. It is important, however, that the dilators are “fitted” to the individual patient and that the woman is instructedto use a generousamount of water-soluble lubricant so that the dilator can be inserted and held in place comfortably. Continued psychological support and reinforcement of proper technique are important. Patients are generally instructed to use the dilator regularly (ie, 10 to 15 minutes a day, two to three times per week), for a period of at least 2 years, as this is when the permanent degreeof tissue scarring seemsto declare itself. If patients have not been using the dilator or having intercourse during this 2-year period, severe or permanent vaginal stenosis can occur. In some cases,surgical reconstruction of the vagina is possible, although there is a further risk of rectovaginal fistula formation with this procedure. Chemotherapy
Despite the progress of modem chemotherapy, this treatmentmodality has limited use in the managementof primary or recurrent cancer of the cervix. Most cancers of the cervix (95%) are of the squamouscell type, and thesetypes of tumors are less responsiveto chemotherapy.For patients who have been previously radiated, drug absorption is compromised with the decreasedtumor vascularity, and myelosuppressiveeffects of the chemotherapy are exaggerated.Pelvic intraarterial infusions of chemotherapyfor patients with recurrent diseasehave been usedwith limited success,since pulmonary toxicity and catheter-relatedcomplications were significanLz6 One of the more promising agentsfor treatment of advancedcervical cancer has been cisplatin.*’ The GGG has studied the efficacy of this agenton patients with advancedor recurrent diseasewhereby a 50% responserate was observed, although only 15% of this group had long-term remission.’ However, investigative trials using 5-fluorouracil or cisplatin chemotherapy along with radiation treatmenthave recently shown encouraging results in patients with advancedprimary disease.28,29Clinical trials are continuing to evaluate the effectivenessof newer drugs such as ifosfamide and tax01in the treatment of advanced cervical cancer.30*3’There is no evidence to show that cervical cancer is sensitive to hormonal therapy.
195
Recurrent or Persistent Disease
Approximately 35% of patients with invasive carcinomawill have recurrent or persistentdisease following therapy.’ Most patients with recurrent diseasepresent with symptoms within 2 years of primary treatment;hence, an intensive follow-up is critical. Becauseof the changesin the cervix following radiation, a punch or needle biopsy is essential for histologic confirmation of suspectedrecurrent disease.The clinical signs and symptoms of recurrent diseaseoutlined in Table 2 are subtle and varied. The prognosis for patients with recurrent or persistentdiseasedependson the extent and location of the disease. When the diseaseis centrally localized with no evidence of lymph node metastases,a radical yet curative surgical intervention (pelvic exenteration) may be considered. For patients presenting with a triad of symptoms, including unilateral leg edema, sciatic pain, and ureteral obstruction, palliative symptom management is required, as this is a classic hallmark of extensive unresectabledisease. Management of patients with recurrent or advanced disease is difficult and challenging. As mentioned earlier, the role of chemotherapy has not been rewarding, and patients with recurrence are often treated symptomatically with analgesics and palliative support. Unilateral or bilateral obstructive uropathy can be treated with urinary diversion or percutaneousnephrostomies.These can be temporarily lifesaving but ethically difficult because patients will suffer unpleasant side effects from the diseaseas well as from efforts to palliate it. Although a once-attractive option, studies indicatethat there is a limited role for urinary diversion in patients with recurrent cancer of the cervix. 32In thesesituations, neither quantity nor quality of survival time is affected in a positive way. The placement of permanent ureteral stents has also been consideredfor patients with unresectablerecurrent disease, yet a similar ethical dilemma is present.
Table 2. Signs and Symptoms
of Recurrent
Cwvicrl
Unexplained weight loss Unilateral leg edema Pelvic and/or thigh/buttock pain Serosanguinous vaginal discharge Left-sided supraclavicular node enlargement Progressive ureteral obstruction Cough, hemoptysis, and/or chest pain Adapted
with permission.’
Cancer
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LESLEE J. THOMPSON
Without decompression,the patient will die of uremia; however, with decompression, the patient may still encounter problems of pain and bleeding becausethe diseaseis progressing. Chronic pain associatedwith disease progression is often quite difficult to manageeffectively. Combinations of antitumor therapy, different classes of analgesics, and behavioral approaches must all be considered. When palliative therapy is of little use or brings further debilitation, psychological interventions may provide some comfort and, secondarily, they may prevent or treat pain sequelae, such as sleep disturbances, reduced appetite, and depression. Total Pelvic Exenteration
Total pelvic exenteration is used only with curative intent for selectpatients who have a localized recurrenceof cervical carcinoma with no evidence of lymphatic involvement. The degreeof radicality used in this operation depends on the extent of diseaseand, hence, a total, anterior, or posterior exenterationmay be performed. Total exenteration involves the removal of all pelvic viscera, including the rectosigmoid and bladder. Occasionally, an anterior exenteration, which preservesthe rectum, or a posterior exenteration, which preserves the bladder, can be performed. After an extensive physical and psychological work-up, surgery is performed in three phases. The first phase is the intraoperative assessmentof diseaseand sampling of pelvic and para-aortic nodes. These nodes are subjectedto immediate frozen section analysis and the results determine whether or not the operation will continue. There have been virtually no survivors after pelvic exenteration of patients who had positive nodes.’ The second “destructive” surgical phase involves the removal of pelvic viscera and other structuresdepending on the patient’s individual situation. The creation of a urinary diversion, colostomy, and neovagina are part of the third “reconstructive’ ’ phase of the exenteration. Urinary diversions may be made with ileal segments, transverse colon, or sigmoid colon con-
duits. Complications tend to be less if the conduits are constructed with unirradiated portions of bowel. Vaginal reconstruction must take place at the time of exenterativesurgery; again, a variety of techniquesare available. Most popular are the sigmoid vaginostomy and the myocutaneousgracilis graft approach. Reports of amnion grafts are encouraging, as this technique is easy to perform, takes minimal time at surgery, and sexual outcomes are positive. 33 Researchdocumenting sexual outcomesand patient satisfaction with the various approaches to vaginal reconstruction are limited; however, comprehensive reviews of the issuesinvolved in sexual rehabilitation for patients undergoing vaginal reconstruction are available.34 Caring for the patient undergoing pelvic exenteration is a tremendous nursing challenge. The need for extensive preoperative counseling and teaching cannot be underestimated,as this is often the key to a successful recovery. Postoperative managementrequires astute assessmentskills to monitor fluid and electrolyte balance, meticulous wound care, and intensive psychological support. A collaborative team approach to patient care is essential if the complex teaching and counseling needsfor thesepatients are to be met. An intensive follow-up plan is often required to facilitate rehabilitation.35 CONCLUSIONS
Caring for the patient with carcinoma of the cervix gives rise to somespecial nursing challengesin the areasof diseaseprevention and early detection, active treatment, and palliative care. The majority of patients are able to enjoy a full survival period following their diagnosis, others must live with the often-distressing long-term effects of their radiation or surgical treatments, and still others succumb to death from disseminateddisease.It is important to understand the physical as well as the psychological processesof recovery from this gynecologic cancer so that the ultimate challenge of the health care team can be met: helping patients live as well as possible until they die.36
REFERENCES 1. DiSaia PJ, CreasmanWT: Clinical Gynecologic Oncology (ed 3). St Louis, MO, Mosby, 1989 2. Silverberg E, Boring CC, Squires TS: Cancer statistics 1990. CA 40:9-26, 1990
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