Preinvasive carcinoma ranges from minimal cervical dysplasia, in which the lower third of the epithelium contains abnormal cells, to carcinoma in situ, in which the full thickness of epithelium contains abnormally proliferating cells (also known as cervical intraepithelial neoplasia [CIN]). Preinvasive cancer is curable 75% to 90% of the time with early detection and proper treatment. If untreated (and depending on the form in which it appears), it may progress to invasive cervical cancer.

In invasive carcinoma, cancer cells penetrate the basement membrane and can spread directly to contiguous pelvic structures or disseminate to distant sites by lymphatic routes. In almost all cases of cervical cancer (95%), the histologic type is squamous cell carcinoma, which varies from well-differentiated cells to highly anaplastic spindle cells. Only 5% are adenocarcinomas. Usually, invasive carcinoma occurs between ages
30 and 50; rarely, under age 20.

Causes of Cervical Cancer

Although the cause is unknown, several predisposing factors have been related to the development of cervical cancer:

frequent intercourse at a young age (under age 16)
multiple sexual partners
multiple pregnancies
exposure to sexually transmitted diseases (particularly genital warts caused by the human papillomavirus)
smoking.

Cervical Cancer Symptoms and Signs

Preinvasive cervical cancer produces no symptoms or other clinically apparent changes. Early invasive cervical cancer causes abnormal vaginal bleeding, persistent vaginal discharge, and postcoital pain and bleeding. In advanced stages, it causes pelvic pain, vaginal leakage of urine and feces from a fistula, anorexia, weight loss,and anemia.

Diagnosis information

A cytologic examination (Papanicolaou [Pap] test) can detect cervical cancer before clinical evidence appears. (Systems of Pap test classification may vary from hospital to hospital.) Abnormal cervical cytology routinely calls for colposcopy, which can detect the presence and extent of preclinical lesions requiring biopsy and histologic examination. Staining with Lugol's
solution (strong iodine) or Schiller's solution (iodine, potassium iodide, and purified water) may identify areas for biopsy when the smear shows abnormal cells, but there is no obvious lesion. Although the tests are nonspecific, they do distinguish between normal and abnormal tissues. Normal tissues absorb the iodine and turn brown; abnormal tissues are devoid of glycogen and won't change color. Additional studies, such as lymphangiography, cystography, and scans, can detect metastasis.

Cervical Cancer treatment

Appropriate treatment depends on accurate clinical staging. Preinvasive lesions may be treated with total excisional biopsy, cryosurgery, laser destruction, conization (and frequent Pap test follow-up) or, rarely, hysterectomy. Therapy for invasive squamous cell carcinoma may include radical hysterectomy and radiation therapy (internal, external, or both).

There are two kinds of radiation treatment: a device loaded with radioactive pellets which is placed into the vagina near the cancer and kept in place for a certain period of time, or an external device which beams radiation into the target areas during visits to the radiotherapist. A variety of chemotherapeutic drugs, or combinations of them, are used. Sometimes radiation and chemotherapy are used before or after surgery.

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Complications

Some types of cervical cancer are less responsive to treatment.
There may be a recurrence of cancer.
Women who are treated with methods that preserve the uterus are at high risk of recurrence.
Surgery and radiation can result in reduced sexual function and altered bowel and bladder function.

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Special considerations or prevention

Management of cervical cancer requires skilled preoperative and postoperative care, comprehensive patient teaching, and emotional and psychological support:

If you assist with a biopsy, drape and prepare the patient as for routine Pap test and pelvic examination. Have a container of formaldehyde ready to preserve the specimen during transfer to the pathology laboratory. Explain to the patient that she may feel pressure, minor abdominal cramps, or a pinch from the punch forceps. Reassure her that pain will be minimal because the cervix has few nerve endings.
If you assist with cryosurgery, drape and prepare the patient as if for a routine Pap test and pelvic examination.
Explain that the procedure takes approximately 15 minutes, during which time the physician will use refrigerant to freeze the cervix. Warn the patient that she may experience abdominal cramps, headache, and sweating, but reassure her that she'll feel little, if any, pain.
If you assist with laser therapy, drape and prepare the patient as if for a routine Pap test and pelvic examination. Explain that the procedure takes approximately 30 minutes and may cause abdominal cramps.
After excisional biopsy, cryosurgery, and laser therapy, tell the patient to expect discharge or spotting for about 1 week after these procedures, and advise her not to douche, use tampons, or engage in sexual intercourse during this time. Tell her to watch for and report signs of infection. Stress the need for a follow-up Pap test and a pelvic examination within 3 to 4 months after these procedures and periodically thereafter.
Tell the patient what to expect post operatively if she'll have a hysterectomy.
After surgery, monitor vital signs every 4 hours.
Watch for and immediately report signs or symptoms of complications, such as bleeding, abdominal distention, severe pain, breathing difficulties, and symptoms of deep vein thrombosis.
To reduce the chances of cervical cancer, girls less than 18 years of age should avoid sexual activity or always use condoms. HPV infection causes genital warts. These may be barely visible or several inches across.
Administer analgesics, prophylactic antibiotics, and subcutaneous heparin, as ordered.
Encourage deep-breathing and coughing exercises.
If a woman sees warts on her partner's genitals, she should avoid intercourse. To further reduce the risk of cervical cancer, women should limit the number of their sexual partners, avoid sexually promiscuous partners, and discontinue any tobacco use. Condoms may help prevent the transmission of HPV.

For radiation therapy:

Find out if the patient is to have internal or external therapy, or both. Usually, internal radiation therapy is the first procedure.
Explain the internal radiation procedure, and answer the patient's questions. Internal radiation requires a 2 to 3-day hospital stay, bowel preparation, a povidone-iodine vaginal douche, a clear liquid diet, insertion of an indwelling urinary catheter, and nothing by mouth the night before the implantation.
Explain to the patient that she'll have less contact with staff and visitors while the implant is in place.
Tell the patient that the internal radiation applicator will be inserted in the operating room WIder general anesthesia and that the radioactive material (such as radium or cesium) will be loaded into it once she's back in her room.
Remember that safety precautions - time, distance, and shielding - begin as soon as the radioactive source is in place. Inform the patient that she'll require a private room.
Encourage the patient to lie flat and limit movement while the implant is in place. If she prefers, elevate the head of the bed slightly.
Check vital signs every 4 hours; watch for skin reaction, vaginal bleeding, abdominal discomfort, or evidence of dehydration. Make sure the patient can reach everything she needs without stretching or straining. Assist her in range-of-motion arm exercises (leg exercises and other body movements could dislodge the implant). If ordered, administer a tranquilizer to help the patient relax and remain still. Organize the time you spend with the patient to minimize your exposure to radiation.
Inform visitors of safety precautions, and hang a sign listing these precautions on the patient's door.
Explain that external outpatient radiation therapy, when necessary, continues for 4 to 6 weeks.
Teach the patient to watch for and report uncomfortable adverse effects. Because radiation therapy may increase susceptibility to infection by lowering the white blood cell count, warn the patient to avoid persons with obvious infections during therapy.
Teach the patient to use a vaginal dilator to prevent vaginal stenosis and to facilitate vaginal examinations and sexual intercourse.
Reassure the patient that this disease and its treatment shouldn't radically alter her lifestyle or prohibit sexual intimacy.

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