SDLP Cervical Cancer

SELF DIRECTED LEARNING PACKAGE
Please see the Disclaimer at the end of this package
Fundamentals of Cervical Cancer
Authors:
Catherine Adams Clinical Nurse

Mercy Colimbo Clinical Nurse
Denise Collins Registered Nurse
Natalie Williams Clinical Development Nurse
Reviewed by: Dr Yee Leung (Consultant & Head of Department,

Gynaecology/Oncology)
Pauline Tanner (Gynaecology Cancer Nurse Co-ordinator)
Gillian Ransom Head (Clinical Nurse Manager, Ward 6)
This package remains the property of WNHS.

Please do not mark the package.
Return to your CDN when completed.
This package has been compiled using information and pictures from a variety of
sources. A full reference list is available at the end of the package.
Name of Package: Fundamentals of Cervical Cancer

Department: Ward 6
Women & Newborn Health Service
King Edward Memorial Hospital
Perth Western Australia
Date Published: November 2009

Date Revised:
Review Date: November 2011
Page 1
CONTENTS
OVERVIEW .................................................................................... 3
AIM ............................................................................................ 3
EXPECTED OUTCOMES ...................................................................... 3
SELF-ASSESSMENT REQUIREMENTS OF THE PACKAGE .................................. 3
WORKING THROUGH THE PACKAGE ....................................................... 4
PRE-PACKAGE TEST ......................................................................... 5
ANATOMY ..................................................................................... 6
AETIOLOGY ................................................................................... 7
EPIDEMIOLOGY ............................................................................... 8
PATHOLOGY .................................................................................. 8
SIGNS & SYMPTOMS ....................................................................... 10
PREVENTION ............................................................................... 10
SCREENING ................................................................................. 10
STAGING & GRADING ..................................................................... 12
TREATMENT ................................................................................ 15
MULTIDISCIPLINARY CARE ................................................................ 18
SURVIVORSHIP ............................................................................. 19
SURVIVAL ................................................................................... 25
CASE EXAMPLE ............................................................................. 26
SUMMARY ................................................................................... 27
POST-PACKAGE TEST...................................................................... 28
REFERENCES................................................................................ 29
DISCLAIMER................................................................................. 31

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OVERVIEW
Welcome to the Fundamentals of Cervical Cancer Self-Directed Learning Package
(SDLP). This package has been developed for nurses and midwives who have limited
knowledge about cervical cancer.
AIM
The aim of this package is to enable the reader to develop an understanding of the
journey of a patient with a diagnosis of cervical cancer so you may provide
accurate information and holistic nursing care.
EXPECTED OUTCOMES
On completion of this package participants will be able to:
Identify the anatomy of the cervix;

Recognise the risk factors for cervical cancer;
Describe the incidence patterns related to epidemiology;
Describe the types of cervical cancer;
Describe the preventative HPV vaccination program;
Understand the screening process and precancerous cell changes that may
occur on the cervix;
Describe the process of diagnosis and staging of cervical cancer and
recognise what the stages represent;
Describe the modes of treatment of cervical cancer;
Identify the psychosocial & sexuality issues that may arise as a result of a
diagnosis and treatment of cervical cancer;
Describe the potential short and long term complications of cervical cancer
and provide nursing care and patient education to reduce the risk of these;
Describe the patients journey through cervical cancer and recognise the
role of the nurse through this experience.
SELF-ASSESSMENT REQUIREMENTS OF THE PACKAGE

To successfully complete this package you will need to complete the following:
Pre-test
Post-test

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WORKING THROUGH THE PACKAGE

The following symbols are used throughout the package to guide your learning.
Application
Symbol
Pre & Post Tests
Linking Theory to Clinical

Practice
Take Time Out or

Stop and Review
Required Reading
Summary
Key Point
For Additional Information

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PRE-PACKAGE TEST
Test your current knowledge by attempting the following questions. If you dont
know the answers, come back to the questions when you find the answers.
1. What factors can contribute to cervical cancer?
____________________________________________________________________
____________________________________________________________________
2. Which part of the cervix is most susceptible to cellular changes?
____________________________________________________________________
3. What are the different cellular types of cervical cancer?
____________________________________________________________________
____________________________________________________________________
4. What is the difference between External Beam Radiation Therapy (EBRT) and
brachytherapy?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5. Which health professionals make up the Multidisciplinary Oncology Team?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6. Name some of the psychosocial & survivorship impacts of cervical cancer &
treatment.
____________________________________________________________________
____________________________________________________________________
7. Name some of the potential complications related to advanced cervical cancer.
____________________________________________________________________
____________________________________________________________________
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ANATOMY
Cervix is the Latin word for neck. The cervix is the neck of the uterus that
connects into the upper part of the vagina.
Internal Os: The opening where the upper part of the cervix joins the uterine
cavity.
External Os: The opening where the lower portion of the cervix joins into the
upper part of the vagina.
Endocervix: The inner part of the cervix which is made of columnar epithelium.
Ectocervix: Refers to the outer part of the cervix and the upper part of the vagina
which is made of stratified squamous epithelium.
Figure 1. Anatomy of the Cervix

(http://medicineworld.org/cancer/lead/7-2006/multiple-hpv-types.html)
Transformation Zone: The point where the squamous epithelium and columnar
epithelium meet, otherwise known as the squamocolumnar junction. This is the
site where the precancerous changes and the cancer most often occur.
Figure 2. Transformation zone

From: Gangar EA. Gynaecological Nursing A Practical Guide. London: Harcourt Publishers Limited;
2001.
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AETIOLOGY
The exact cause of cervical cancer remains unknown. Cervical cancer can occur in
any woman however there are a number of associated risk factors that have been
identified:
HPV Viral infection, namely Human Papillomavirus (HPV) infection, is the

most important factor in development of cervical neoplasm, preinvasive and
invasive, with 99% of all cervical cancers attributed to HPV (1). HPV includes
more than 100 types of viruses but the HPV types most commonly associated
with cervical cancer are types 16 and 18, and are transmitted during sexual
activity(2-3).
Early age of intercourse Sexual intercourse before 18 years of age increases

the risk of cervical cancer due to the less mature cervical cells being more
susceptible to the precancerous changes triggered by HPV infection(3).
Number of sexual partners The more sexual partners a woman has the
greater the risk of developing cervical cancer. Having six or more sexual
partners increases the risk of developing severe dysplasia. It is also suggested
that a woman has an increased risk of developing cervical neoplasia if her
partners previous female partner had cervical cancer(4).
Smoking There is a link between cigarette smoking and a decrease in the

number of Langerhans immune cells in the cervical epithelium. This suggests
that the immune response to a HPV exposure will be decreased(1).
Immunosuppression Women who are taking immunosuppressive medications

are at risk of developing cervical cellular abnormality(4).
Lower socio-economic status The incidence of cervical cancer is higher in

poor and uneducated women living in rural communities compared to women of
higher socioeconomic status(3).

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EPIDEMIOLOGY
Around the world cervical cancer is the second most common cancer in women
after breast cancer. Each year, almost half a million women are diagnosed and a
quarter of a million women die from this disease. In Australia in 2004, cases of
cervical cancer were highest in women aged between 30 to 34 years and most
cases are found in women under 60 years of age. (5)
As shown in Figure 3 below, the incidence rate of cervical cancer is higher in
undeveloped or developing nations and least in developed nations. (6) There are a
significantly reduced number of women who develop or die from the disease in
countries where the cervical screening programme is available and easy to access.
(6)
Figure 3. International Incident Patterns

Rates per 100,000 woman-years, age-adjusted using the world standard
(http://dceg.cancer.gov/research/healthdisparities/cervical)
PATHOLOGY
Human Papillomavirus (HPV)
HPV is transmitted by skin to skin contact and enters through breaks in the skin and
mucous membranes. The HPV invades the epidermal layer only and as there is no
invasion into the dermis, the body doesnt mount an immune response(4). This
means there are no detectable clinical signs (i.e. shown by blood tests). In
Australia, 80 to 90% of sexually active women become infected with HPV each year
(7) and the prevalence in women with only one lifelong partner is up to 20% (4).
Preinvasive Stage
Cervical cancer has a pre-invasive stage, Cervical Intraepithelial Neoplasia (CIN),
which can be detected through smear tests. CIN is a condition of the cervix where
there are abnormal cells present on the surface of the cervix, otherwise known as
cervical dysplasia, benign precancerous changes.
There are 3 classifications of CIN:
CIN 1 - Mild to moderate dysplasia. Low grade, affects less than one-third
full thickness of the cervical epithelium and often clears up without
treatment, but a repeat smear test is needed to check.
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CIN 2 Intermediate grade, affects half to two-thirds full thickness of the

epithelial layer.
CIN 3 Severe dysplasia or high grade and affects two-thirds to full
thickness. (1, 3, 8)
Types of Cervical Cancer

There are two types of cells that line the surface of the cervix. The cells that are
in the middle and upper third of the cervix close to the lining of the uterus have a
column-shaped or columnar appearance and are called glandular cells. The cells
lining the bottom third of the cervix are thin, flat cells and are called squamous
cells. The boundary between these two types of cells is called the transformation
zone or the squamocolumnar junction and it is here that cervical dysplasia and
cancer usually occurs. See figure 4 below.
Figure 4. Cell types at the transformation zone of the cervix

From: Hartmann LC, Loprinzi CL. Mayo Clinic Guide to Women's Cancers. 1 ed. Rochester: Mayo Clinic
Health Information; 2005.
These cells can develop into different types of cancer which include the following:
Squamous cell carcinomas develop from the cells covering the outer
surface of the cervix at the top of the vagina (ectocervix). 85 90 % of all
cervical cancers.
Adenocarcinomas develop from the glandular cells lining the cervical canal
or in the upper portion of the cervix (endocervix). 10 15 % of all cervical
cancers.
Adenosquamous carcinomas are rare, mixed cell types which contain
features of both squamous cell and adenocarcinoma.
Small cell carcinoma and cervical sarcoma are the other rare cancer types
that can develop in the cervix (<1% of all cervical cancers). (3, 8)

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SIGNS & SYMPTOMS

Early stage disease has virtually no signs or symptoms. A watery discharge may be
noted which will eventually become abnormal vaginal bleeding, often post coital
but also intermenstrual or post menopausal. Heavy bleeding can lead to anaemia.
Symptoms are usually associated with disease progression and may include:
lower back pain (with parametrial involvement);
urinary symptoms such as hydronephrosis (distension in kidney caused by
ureteric obstruction)(9), haematuria and frequency (with bladder invasion);
bowel symptoms such as constipation and/or diarrhoea and pain on
defecation; and
vesico-vaginal, ureterovaginal or rectovaginal fistula. (4)
PREVENTION
The HPV vaccine was approved for use in Australia in 2007. The vaccine is a
recombinant immunisation against HPV strains 6, 11, 16 and 18. HPV strain 16 is
associated with 50 to 60% of squamous cell cervical cancers and HPV 18 with 10 to
15%. Another 18% of these cancers are linked with 5 other HPV strains. The
vaccination has been tested as 100% effective against the four targeted HPV
strains(10).
In Australia, the HPV vaccination program has been introduced into schools by
offering the 3-dose program to all 12 to 13 year old females so that they gain
immunity prior to becoming sexually active and being exposed to the virus(11).
The vaccination is administered in three dose at 0 months, 2 months and 6 months.
Efficacy of the vaccine in women over 26 years is yet to be proven (10).
SCREENING
The primary aim of screening for cervical cancer is to reduce the incidence and
mortality from cervical cancer.(4) Screening for any disease should only take place
when there is a recognisable preinvasive stage, a benefit to early treatment, a
readily available screening test and a cost benefit(4).
In Australia, the Department of Health and Aging established the National Cervical
Screening program in 1991. The Australian policy recommends pap smears every
two years from 18 years of age, or one to two years after becoming sexually active.
Pap smears may cease at age 70 providing the woman has had two normal pap
smears in the last 5 years (11). Screening for cervical cancer is primarily by pap
smear and if abnormalities are identified, followed up by colposcopy (12).
For more information on screening for cervical cancer in
Australia, visit the website www.cancerscreening.gov.au
For information on screening programs in other countries, refer
to
Lancaster T, Nattress K. Gynaecological Cancer Care Nursing: A
Guide to Practice. Melbourne: Ausmed Publications Pty Ltd; 2005.
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Pap (Papanicolaou) Smear

A pap smear is performed by inserting a speculum into the vagina, visualising the
cervix and, using a wooden or plastic Ayers spatula, cells are scraped from the ecto
and endo cervix. These are then spread onto a glass slide and fixed with alcohol
(see Figure 5). An endocervical brush can also be used to sample cells from the
endocervical canal but this test is not currently covered by Medicare. (4)
Figure 5. Pap smear procedure

(http://www.firstvisitivf.org/content/dan_braun.htm)
The advantage of the pap smear as a screening test is that it is relatively cheap
and easy to perform. The disadvantages are poor compliance by some women, the
high number of false negative smears reported, and the fact that not all tumours
exfoliate abnormal cells(13). Cervical adenocarcinoma, in particular, arises in the
endocervix and may therefore not be reached by routine pap smear sampling.
The sensitivity of pap smear sampling, i.e. the number of women with abnormal
cells who are identified through pap smear, has been reported as between 44% and
96%. However the specificity, or the number of women without abnormal cells
who are identified (i.e. false positives) has been reported as between 91 to 98%.
Repeat testing improves the accuracy of the results (14).
Colposcopy
Colposcopy involves microscopic examination of the cervix. Again, a speculum is
inserted into the vagina and the cervix visualised. The cervix is examined by the
clinician using a colposcope which is a low power binocular microscope (see Figure
6). The cervix is stained with acetic acid and then iodine which stains any abnormal
epithelium. Biopsy and, if appropriate, treatment can be performed. This
examination does not require a general anaesthetic.(15)

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Figure 6. Colposcopy procedure

(http://www.hopkinsmedicine.org/cervicaldysplasia/treatment_1.htm)
STAGING & GRADING

Staging is the formal classification of the extent of disease at diagnosis. It allows
an accurate international comparison of response to various treatment regimes
and, from this information, helps in the establishment of guidelines for specific
treatment regimes for patients with the same stage of disease. It also provides
useful data for estimating prognosis.(16)
Most types of cancers are classified by the TNM method at diagnosis (tumour type,
lymph node involvement and metastasis). However, in gynaecological cancer, the
International Federation of Gynaecology and Obstetrics (FIGO) staging system is
used (see KEMH Clinical Guideline 13.2.1). Once the stage of cervical cancer is
known then a treatment pathway will be recommended.
Staging for cervical cancer is clinical, meaning it is based on a visual, clinical
assessment of the patient, as opposed to surgical staging. Cervical cancer may be
staged clinically on histological assessment of tissue usually obtained by punch
biopsy during colposcopy. A review of literature (2, 4, 15-16) states that staging
comprises of 3 elements:
1. Examination under anaesthetic (EUA);
2. Chest x-ray; and
3. Intravenous pyelogram (IVP).
The practice at KEMH (according to Clinical Guideline Section C, 13.2) is to perform
an EUA, which consists of cystoscopy and proctosigmoidoscopy, chest x-ray (looking
for distant metastases) and CAT, PET or MRI scan (to determine spread within the
pelvis). The CAT, PET or MRI scan negates the need for an IVP but the scan results
are not incorporated in the staging information, because staging is international
and some developing countries may not have access to such advanced scanning
facilities.
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Once the clinical assessments have taken place, the stage will be determined
based on the FIGO system for cervical cancer shown in Table 1 below.
II
III
IV
FIGO Stage
Stage 0
Definition
Carcinoma insitu involving epithelium only
(corresponds to CIN)
Stage I
Cervical carcinoma strictly confined to the
cervix
Stage IA
Invasive cervical cancer diagnosed by
microscopy only
Stage IA1
Stromal invasion no deeper than 3mm, no
wider than 7mm in horizontal spread
Stage IA2
Stromal invasion greater than 3mm but less
than 5mm in depth and no wider than 7mm
Stage IB
Clinically visible lesion confined to cervix or
microscopic disease greater than stage 1A
Stage IB1
Lesion not greater than 4cm in size
Stage IB2
Lesion greater than 4cm in size
Stage II
Tumour extends beyond cervix but not to
pelvic sidewall or lower 1/3 vagina
Stage IIA
Vaginal involvement without parametrial
involvement
Stage IIB
Obvious parametrial involvement
Stage III
Tumour extends to sidewall and/or causes
hydronephrosis and/or extends to lower 1/3
vagina
Stage 111A
Involvement lower 1/3 vagina with no spread
to side wall
Stage IIIB
Extension to pelvic sidewall and/or
hydronephrosis
Stage IV
Extension beyond the true pelvis or into
mucosa of rectum or bladder
Stage IVA
Spread into adjacent organs
Stage IVB
Spread into distant organs
Table 1. FIGO staging for cervical cancer (17)
In addition to staging, cervical cancer is also classified by a Grading System. The

grade is determined by examining the biopsy specimen under a microscope and
gives an indication of how quickly the cancer may grow.
Grade 1: (low grade or well differentiated) is usually slow growing and looks
similar to normal cells.
Grade 2: (medium grade or moderately differentiated) looks more abnormal and is
slightly faster growing.
Grade 3: (high grade or poorly differentiated) cells look very abnormal and tend to
grow much faster and are more likely to spread than grade 1 cancer cells. (18)

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KEY POINT
Staging is the classification of the extent of disease at diagnosis, so once the stage
of the cancer has been initially identified, it will remain the same throughout the
disease progression. In other words, if a patient was diagnosed two years ago as a
cervical cancer stage IIB and presents with complications relating to her
widespread metastases, her stage does not change to reflect the metastases. She
is still said to have stage IIB cervical cancer (with metastases).
Figure 7. Cervical Cancer Stages I - IV

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Figure 8. Cervical Cancer Early Stages I IIB

(http://www.tribalconnections.org/health_news/features/aug2006p1.html)
TREATMENT
The treatment for cervical cancer depends on the disease stage and the patients
age. Fertilitysparing treatment may be offered to the young patient who is keen
to pursue having children. The treatment offered to a patient may involve surgery,
chemotherapy and radiotherapy, or a combination of all three (19) (See Table 2
below). The prognosis depends on the type of cancer and the extent of the disease.
For further information on treatment for CIN (i.e. LLETZ) see

Monga A. Gynaecology by Ten Teachers. 18 ed. London: Hodder
Education; 2006.
For further evidence-based information on treatment for each
stage of cervical cancer, visit the National Institute for Cancer
(US) website
http://www.cancer.gov/cancertopics/pdq/treatment/cervical
/HealthProfessional/page1
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STAGE
1A1
TREATMENT GUIDELINES
Cone biopsy
Total hysterectomy
1A2-1B
Radical hysterectomy with bilateral pelvic lymphadenectomy
Radical trachelectomy with bilateral pelvic
lymphadenectomy
Concurrent chemo-irradiation (Cisplatin with External Beam
Radiation Therapy (EBRT) and then brachytherapy)
11A
Radical hysterectomy with bilateral pelvic lymphadenectomy
Concurrent chemo-irradiation (Cisplatin with EBRT, then
brachytherapy)
11B-1VA
Concurrent chemo-irradiation (Cisplatin (and possibly other
chemo drugs) with EBRT, then brachytherapy)
1VB
Local treatment with radiotherapy to symptomatic
metastases
Systemic chemotherapy
Table 2. Recommended treatment based on stage of cervical cancer (20)
Review:
Refer to KEMH Clinical Guidelines available in
Section C, 13.2 for further information on staging
and treatment.
Cone Biopsy
This is the surgical removal of a cone-shaped segment of the cervix, including both
ectocervical and endocervical tissue. (9)
Lymphadenectomy
This is the surgical removal of lymph nodes, also known as lymph node dissection
(LND), either bilateral or unilateral. In cervical cancer this usually includes the
external iliac, internal iliac, common iliac, obturator and presacral nodes. (9, 15)
Radical hysterectomy
In a radical hysterectomy or Wertheims hysterectomy, the whole uterus is
removed together with the upper third of the vagina, parametria and the pelvic
lymph nodes with or without the para-aortic nodes.
Due to disruption to the nerves during a radical hysterectomy, this surgery is
associated with bladder dysfunction, in particular difficulty initiating voiding and
inadvertent damage to the ureters. (4) After surgery, patients are followed up with
a limited IV pyelogram to check patency of the ureters. Usual practice at KEMH is
to leave the indwelling catheter in situ for approximately 5 days.
Radical trachelectomy
This surgery involves removing the cervix, together with the top 2-3cms of the
vagina and joining the top of the vagina to the lower segment of the uterus. This
surgery is used in an attempt to preserve fertility(19). It was first described only
12 years ago and is uncommonly practiced in Australia(21).

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Radiotherapy
Radiation therapy involves the use of X-rays to kill cancer cells. Radiotherapy to
the pelvis may be delivered by external beam, and/or an internal source (often
referred to as brachytherapy), or high dose radiotherapy (HDR). (3) External beam
radiotherapy (EBRT) is used to shrink the central carcinoma and also treat the
possible sites of regional metastasis. (15) Internal radiation (brachytherapy) is
when the source of radiation is sealed within a container called an implant. An
implant is placed directly into the cervix or vagina. (3) (See Figure 9 below)
Figure 9. Radiation Therapy

Chemotherapy
Chemotherapy is the use of cytotoxic agents to destroy cancer cells. Combination
chemotherapy is where the mechanism of different drugs complement each other
to produce maximal cell kill-synergy. (20)
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Treatment Regime
As outlined in Table 2 (above), most treatment of cervical cancer involves
concurrent regimes of chemotherapy, external beam radiation and brachytherapy.
All patients are treated individually depending on the stage and grade of their
cancer as well as if there is nodal involvement.
A normal weekly regime for a patient may be to receive low dose Cisplatin
chemotherapy on Monday mornings with radiation therapy in the afternoon and
radiation daily for the following four days. External beam radiation therapy is
given daily (weekdays) for approx 28 treatments (5 weeks) and then four
treatments of high dose brachytherapy, 2 per week for 2 weeks. Low dose
Cisplatin has been shown to increase the effectiveness of the radiation therapy.
High risk or metastatic cancers will have a significantly different regime to this.
(22)
Practical Activity
It is possible to organise a tour of the Perth Radiation
Oncology centre as well as to visit the chemotherapy unit
at Sir Charles Gairdner Hospital.
MULTIDISCIPLINARY CARE
For best outcome, women with a gynaecological cancer should be referred directly
to a Gynaecological Oncologist and have access to a multidisciplinary health care
team offering the full range of supportive services. Women who live in rural and
remote areas of WA would have this care co-ordinated by their GP local specialist
and Regional Cancer Nurse Coordinator, linking with the metropolitan based Cancer
Nurse Coordinator for Gynaecology. (23)
In WA, the Tumour Board are a specialist gynaecological oncology team who meet
weekly to review, discuss and determine the management of newly diagnosed
patients and those presenting with a recurrence or disease progression (case
conference). The Tumour Board meet on a Thursday morning, alternatively at
KEMH and SJOG hospitals, and treatment for women with a gynaecological cancer
will be planned after all relevant investigations such as pathology reports, CT scan
results etc have been reviewed and discussed. (23) The functions of the Tumour
Board are:
to determine diagnosis
to make a treatment plan
provide an education forum.
Members of the Tumour Board Multidisciplinary Team include:
Gynaecological oncologist
Radiation Oncologist
Medical Oncologist
Palliative care physicians
Gynaecologic histopathologist/cytologists
Radiologists
Cancer nurse Co-ordinator
Oncology Liaison Nurse
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At KEMH, a Multidisciplinary Team incorporating Allied Health also meet weekly on

Tuesday mornings at 0930 to discuss the needs of current oncology inpatients and
how each team members role can contribute to the holistic care needs of these
patients.
Members of the Multidisciplinary Team include:
Gynaecological oncologist, Registrar and Resident Medical Officer
Social worker
Clinical Psychologist
Pastoral Care
Physiotherapist
Pharmacist
Dietician
Occupational Therapist
Ward 6 Registered Nurse
Gynaecology Cancer nurse Co-ordinator
Oncology Liaison Nurse
Practical Activity
Nurses are encouraged to participate in these
Multidisciplinary Team Meetings when time permits.
SURVIVORSHIP
SEXUALITY
Women who have been treated for cancer of the cervix live with the emotional and
physical consequences this has on the lives of themselves and their loved ones.
Cancer of the cervix and subsequent treatments, including surgery, radiotherapy
and chemotherapy can have a temporary or permanent affect on a womans
sexuality. (24) Women who have been treated for cervical cancer often have
persistent vaginal changes that may compromise sexual function and can result in
considerable distress(20). These affects may include both psychological and
physical symptoms.
Psychological symptoms may include: (16)
Disruption of body image
Loss of femininity
Loss of self-esteem
Loss of wholeness as a woman
Fear of rejection
Losing interest in sex
Young women feeling out of sync with their peers
Physical symptoms may include: (24)
Fatigue
Trouble reaching orgasm
Vaginal dryness
Premature menopause
Exacerbation of menopausal symptoms
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Reduced vaginal size and vaginal stenosis

Painful penetration and/ or intercourse
Infertility temporary or permanent
Surgery
The effect on a womans sexuality will depend on the exact nature of the surgery
performed. For example, following a radical hysterectomy there is nerve and
vascular disruption to the pelvis and shortening of the vagina which may cause
painful intercourse with deep penetration. Following a bilateral-oophrectomy,
premenopausal women may experience menopausal symptoms including decreased
vaginal lubrication causing painful intercourse. (16)
Radiotherapy
Pelvic radiation therapy is associated with a number of side effects. Commonly
described short term side effects include erythema, oedema and muscositis,
diarrohoea and cystitis. Longer term side effects include vaginal stenosis, vaginal
vault scarring and adhesions, radio-necrotic ulcers, fistula formation and
alterations in cervico-vaginal secretions. (25)
Up to 88% of women who receive pelvic radiotherapy are at risk of developing
vaginal stenosis.(26) This may result in a shortening and narrowing of the vagina,
adhesions, scarring and loss of elasticity and lubrication of the vaginal tissue.
Thinning of the tissue results in bleeding which can lead to dyspareunia and
preclude clinical examination, a necessary part of follow up care. In order to
maintain a healthy and functional vagina, women post pelvic radiotherapy need to
use vaginal dilators.(4)
Review: Best Practice Guidelines on the use of
vaginal dilators in women post pelvic radiotherapy
are available online through the UK Oncology Nursing
Society at www.ukons.org/downloads
Chemotherapy
Chemotherapy may affect sexuality in a number of ways. It may bring on
premature menopause including decreased vaginal lubrication, vaginal atrophy,
weight loss, nausea and vomiting. (24) Lethargy in particular may be a significant
barrier to healthy sexual function. This fatigue often persists for months after
completion of treatment. Exercise during and post treatment has been shown to
be helpful. (27)
Review: The Cancer Council have published a
pamphlet Sexuality for Women with Cancer: a guide
for women with cancer, their families and friends
that gives practical tips that may help women
overcome some of these problems.
LYMPHOEDEMA
Secondary lymphoedema can occur when the lymph nodes are removed by surgery
or damaged by radiotherapy which can occur following treatment for cancer.
Lymphoedema may occur in the legs if pelvic nodes are removed in the treatment
for cervical cancer. (28)
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Patient education in recognising the signs of lymphoedema can have a significant

impact on reducing the potential severity of this condition. Patients with
lymphoedema are particularly prone to recurrent cellulitis due to the high protein
content of the lymph. It is essential that nursing care involve significant patient
education in skin care and other infection risk-reduction interventions as well as
referring at risk women to physiotherapy for education and leg measurements prior
to discharge.
Education should include advice such as:
Good skin care to ensure skin acts as barrier to infection, i.e. regular
moisturising, avoiding skin damage;
Avoiding constrictions, i.e. tight clothes, shoes;
Good foot hygiene & cleanliness;
Use of gloves, covered footwear & long pants for tasks with infection risk,
i.e. gardening;
Strategies to avoid insect bites and sunburn;
Recognising signs of infection/cellulitis so treatment may be prompt;
Weight management, health diet & exercise to promote optimal lymphatic
flow. (28)
For Additional Information:
For further information on lymphoedema, refer to the
National Breast and Ovarian Cancer Centre leaflet,
Secondary Lymphoedema: A Guide for Health
Professionals, available at www.nbocc.org.au.
Figure 10. Lymphoedema of the left leg

(http://www.lymphoedemasupport.com/secondary.php)
Access the Rural Health Education Foundation website

www.rhef.com.au and view the program on The
Management of Secondary Lymphoedema (50 minute
program). This program is free to access online
(registration is required).

Department: Ward 6

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FISTULAE
A fistula is an abnormal opening between epithelial surfaces(4). In cervical
cancers, three types of fistula may occur:
vesicovaginal (between bladder and vagina)
ureterovaginal (between ureter and vagina)
rectovaginal (between rectum and vagina)
Figure 11. Sites of genitourinary fistulae (female)

From: Farrell M. Smeltzer and Bare's textbook of medical-surgical nursing. 1st ed. Broadway:
Lippincott Williams & Wilkins Pty Ltd; 2005.
The first two are more common and are related to surgery. The latter is less
common and usually related to pelvic radiation(29-30). One American study
discussed that of 536 women undergoing radical hysterectomy for cervical cancer,
2.6% developed a vesicovaginal fistula, and 2.4% developed a ureterovaginal
fistula(29).
The patient will experience symptoms of continuous urinary leakage (vesicovaginal
& ureterovaginal) or faecal discharge through the vagina (rectovaginal). Diagnosis
results from clinical examination with a speculum, methylene blue dye test and/or
intravenous pyelogram(7).
Treatment may or may not involve surgery but in either case nursing care should
focus on promoting good personal hygiene, odour management, incontinence/skin
care, preventing infection, education on diet to promote healing (low residue for
rectovaginal, otherwise high protein), rest, and offering the patient the
opportunity to discuss impact on their sexuality and general lifestyle. Surgical
treatment for complex cases may involve urinary or faecal diversion, i.e. stoma(7).

Department: Ward 6

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URETERIC COMPRESSION & STENTS

Ureteric compression is another potential complication of advanced cervical
carcinoma and is usually caused by progressive tumour.
Ureteric compression may be diagnosed by:
biochemical studies (U&Es) (i.e. an elevated serum creatinine may be
noted) and
decreased urinary output.(7)
Hydronephrosis is a condition where obstruction to the ureters cause backward
pressure on the kidney structures and distention, and can result in permanent
damage to kidney structures and function. Symptoms include flank pain, and
sometimes haematuria, pyuria and hyperpyrexia.(9)
Treatment is often insertion of a ureteric stent (typically a double-J or pigtail
stent) usually inserted via a cystoscopy but can be by open surgery.
Figure 11. Double-J (JJ) stent

(http://www.swanseaurology.co.uk/index.php?page=jj-stent)
Nursing care related to a patient with a stent includes monitoring the patient for
bleeding, strict fluid balance recording, and assessing for infection, particularly
UTI or retroperitoneal from urinary leakage. Colicky pain and/or decreased urine
output may indicate a displaced stent. Stents may be occluded by pus, tumour or
blood clot requiring surgical intervention. Stents may be required indefinitely but
need to be replaced at regular intervals. (7)
PAIN MANAGEMENT
For women suffering from cervical cancer, over 70% will experience cancer pain(4).
The pain may be due to:
- effects of the cancer itself;
- treatments such as surgery, chemotherapy or radiotherapy; or,
- other causes, e.g. constipation, bony mets, UTI, chest infection, pressure
sores, positioning for comfort, haemorrhoids and fear and anxiety. (4, 31)

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A thorough assessment of the patient is therefore essential in being able to manage

the patients pain effectively and pain relief medication should always be
monitored for effect.
In patients with advanced cervical cancer, the pain can be difficult to treat and
referral to a specialist team (i.e. palliative care or pain service) is often
required(4).
Commonly, these specialists will adopt the principle of multi-modal analgesia. This
principle involves the prescription of sub-maximal doses of two, three or more
drugs that maximise analgesia effect but have fewer adverse effects than a
maximal dose of one single drug. This involves both opioid and non-opioid
analgesia for regular and breakthrough pain. These may include simple analgesia
(i.e. paracetamol), NSAIDs (i.e. ibuprofen), weak opioid (i.e. tramadol), opioid
(i.e. oxycontin, morphine or fentanyl) and adjuvant pharmacological therapies (i.e.
anticonvulsants, aperients, antiemetics and antidepressants)(32).
The role of the nurse is central to evaluating the effectiveness of the analgesia,
the type of pain (i.e. somatic, visceral or neuropathic) and identifying when
analgesia requirements exceed what is prescribed. Education of the patient in
managing their pain is essential to promote self-control, using both
pharmacological and adjuvant treatments, including relaxation, distraction
therapy, hot packs etc.
PSYCHOSOCIAL ISSUES
Women undergoing treatment for cervical cancer will not only need to cope with
the physical changes and effects of their treatment, but also many other
psychosocial issues that relate to a cancer diagnosis.
Such issues include:
Financial impact (i.e. cost of treatment, loss of income)
Emotional impact (on themselves and their family and friends)
Relationships (spouse, children, parents, friendships)
Fear of recurrence

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SURVIVAL
The survival rate for women with early diagnosed cervical cancer after five years is
high. (6) See table 3 below.
STAGE
FIVE YEAR SURVIVAL

(approx %)
Ia1
98
Ia2
95
Ib1
85
Ib2/IIa
75
IIb
65
IIIa/b
30
IVa
10
IVb
5
Table 3. Five year survival by stage of cervical cancer (6)
Women who have had a hysterectomy are followed up during their clinic
appointments with regular vault smears, i.e. swabbing of the cells from the upper
vaginal vault, to ensure that there is no recurrence of abnormal cells. Educating
patients on the need for follow-up is essential to help detect recurrence early.
If a woman presents with recurrent cervical cancer, she can receive further
treatment dependent on her primary treatment, for example she may be treated
with radiotherapy only if the initial treatment was only surgery. This is due to the
nature of radiation therapy as a cumulative treatment.
If the recurrence occurs centrally in the cervix a radical surgical procedure called a
pelvic exenteration may be considered. This involves the formation of a colostomy
and an ileal conduit, and the removal of the bladder, rectum, uterus, fallopian
tubes and ovaries, cervix and vagina. (19) The post procedure survival rate after
five years is up to 50 %.(6)
Palliative care in cervical cancer involves the management of symptoms such as
pain, lymphoedema, malodourous discharge, vaginal bleeding, renal failure, and
fistulae. Renal failure can occur as the ureters become compressed and ureteric
stenting can be considered for these women. (6) Pain can be very problematic in
women with cervical cancer and therefore the involvement of a specialist palliative
care physician is essential.

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CASE EXAMPLE
Kate, a 47 year old woman, attends her GP with a 6 month history of post coital
bleeding. Her pap smear is attended to with a result of CIN3. She is subsequently
referred to a gynaecologist/ gynaeoncologist and attends her appointment approx 6
weeks later. A colposcopy biopsy is performed and SCC is identified on the biopsy.
Kate is reappointed for a LLETZ procedure approx 3-4 weeks later. After this
procedure, moderately differentiated SCC is identified and Kate is now referred to
gynae-oncology team at KEMH.
At her first clinic appointment, a detailed history is taken and Kate is booked for
clinical staging, including an EUA, cystoscopy and proctosigmoidoscopy, in one
months time. A CAT scan (or PET) is also booked. Post EUA & CAT, staging
determines a Stage 1b grade 2 squamous cell carcinoma of the cervix. Kate is now
booked for surgical treatment in 6 weeks time.
Kate attends preadmission clinic the week before surgery and meets the oncology
liaison nurse and members of the gynae onc team. The social worker is also
available if any issues are identified. Kate is informed she will be admitted on the
day of her surgery to Day Surgery Unit and then be nursed post-operatively on the
gynaecology ward. Pre-operatively, Kate is advised to have a low residue diet two
days pre op and clear fluids the day before. She is advised to take a bowel prep
consisting of one sachet pico prep on the afternoon prior to surgery. On the
morning of her operation, TEDS are fitted and a clip of pubic hair is performed.
The operation performed is a laparotomy, radical hysterectomy, bilateral
salpingoopherectomy and pelvic lymph node dissection. On return to the ward Kate
has an epidural infusion for analgesia, a midline incision covered with thin
duoderm, a urinary catheter and IV hydration. She has oxygen therapy until she is
fully awake and is allowed post op fluids until she passes flatus. Heparin 5000 units
subcutaneous is prescribed TDS and TEDS are worn.
Kate has a routine recovery and by day 3 the epidural is removed, her bowels have
opened and she goes on to pass her trial of void after her urinary catheter is
removed on day 5. Her histopathology stated that she has grade 2 SCC cervix . She
is given an appointment to see the medical oncologist and the radiation oncology
consultant at KEMH to plan further treatment two weeks after discharge from
hospital. She is also referred to ultrasound for a limited IVP to check ureteric
patency one week after her surgery.
Understandably, Kate appears to have difficulty in dealing with her diagnosis and
during her admission the nursing staff take the opportunity to ask her about how
she is coping with this news. Kate discloses she was widowed 6 years previously
when her husband died from oesophageal cancer despite surgical treatment
combined with radiation and chemotherapy. Kate initially appears very reluctant to
accept the need for these treatments as she feels she is going to die anyway. The
oncology clinical liaison nurse is asked to visit Kate to provide education specific to
her cancer and prognosis and to help her make an informed decision about her
treatment options.
Department: Ward 6

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Page 26
Another concern for Kate is being in a new sexual relationship. She met a new
partner one year ago who is very supportive but Kate has concerns that he might
not find her sexually attractive and has some fears regarding being physically able
to enjoy a fulfilling sex life. The nurse provides Kate with information on the use
of vaginal dilators and advice on sex as a means of preventing vaginal stenosis as a
side effect of her radiation therapy. Her partner is also involved in a conversation
about sexuality and he expresses fear about possibly hurting Kate when resuming
intercourse and has concerns that sex may have contributed to her developing
cancer. They are encouraged to remain open and physically expressive but to wait
until after Kates 6 week post op check before attempting penetrative sexual
intercourse again. As well as this verbal advice, Kate is given the brochure
produced by the Cancer Council, Sexuality for Women with Cancer.
Also during Kates admission, the nursing staff take the opportunity to educate her
in recognising signs of lymphoedema, due to her surgery involving removal of the
pelvic lymph nodes. This would involve encouraging Kate to seek advice at the
earliest sign as early intervention will give her the best chance of management.
Prevention techniques, such as skin care is also essential. Kate is given written as
well as verbal information and encouraged to ask questions.
Kate subsequently went on to have chemotherapy (Cisplatin) on Mondays (at SCGH)
concurrently with daily radiotherapy treatments (at RPH) for five weeks and four
brachytherapy treatments in the final week. She experiences some nausea on her
chemotherapy days but never actually vomits. She complains of extreme fatigue
during her chemo /rads treatment and is encouraged to ensure she eats a good
quality high protein diet and incorporate regular rest periods into her daily routine.
She was also encouraged to continue a programme of regular light exercise.
Kate is followed up every four months at KEMH out patients clinic. At her
appointments, she receives a vault smear to check for any potential dysplasia of
the cells in the upper vaginal vault. At two years after her diagnosis, Kate
continues to be disease free.
SUMMARY
Cervical cancer is a significant health issue for women internationally, but many
cases may be preventable with early intervention and screening. Health
professionals have a central role in providing women with the education they need
to help prevent the development of cervical cancer, and in those women with
diagnosed cervical cancer, help improve their outcomes and quality of life.
The future looks bright with the recent introduction of the HPV vaccination
program and the prediction that cervical cancer rates in Australia will continue to
decrease over the coming years.

Department: Ward 6

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Page 27
POST-PACKAGE TEST
Complete the following multi-choice questions to test your knowledge as a result of

this package.
1. The majority of cervical cancers are:
(6)
a)
b)
c)
d)
Squamous cell carcinomas

Adenocarcinomas
Small cell carcinomas
Melanomas
2. Risk factors for cervical cancer

include: (6)
a)
b)
c)
d)
Smoking
Immunosuppression
Human papillomavirus (HPV)
All of the above
3. Which type of epithelial cell lines the

endocervical canal?: (6)
a)
b)
c)
d)
Columnar
Squamous
Cuboidal
Pseudostratified columnar
4. If a pap smear detects abnormal

cells, the follow up procedure to
microscopically examine the cervix is
called a:
a)
b)
c)
d)
Colonoscopy
Colposcopy
Colpotomy
Colloscopy
5. Stage IIb of cervical cancer is

characterised by: (6)
a) Obvious parametrial involvement
b) No obvious parametrial
involvement
c) Carcinoma extending to the
pelvic wall
d) Carcinoma extending to adjacent
organs

Department: Ward 6
6. Why are CAT scan results not

incorporated into staging
information?
a) CAT results are irrelevant
b) Staging doesnt include
metastases
c) Staging is international & some
developing countries dont have
CAT machines
d) Cervical cancer staging is surgical
7. Treatment for cervical cancer may
include: (6)
a)
b)
c)
d)
Surgery
Radiotherapy
Chemotherapy
All of the above
8. Surgical removal of lymph nodes is

termed: (6)
a)
b)
c)
d)
Lymphadenopathy
Lymphangiectasia
Lymphorrhagia
Lymphadenectomy
9. What effect does cervical cancer

treatment have on a womans sexual
function?
a)
b)
c)
d)
e)
Vaginal scar tissue formation

Fatigue
Vaginal dryness
Disruption of body image
All of the above
10. The five year survival rate for stage

IVb of cervical cancer is estimated at:
(6)
a)
b)
c)
d)
2%
5%
65%
85%

Date Revised:
Page 28
REFERENCES
1.
Bedford S. Cervical cancer: physiology, risk factors, vaccination and
treatment. British journal of nursing. 2009;18(2):80-4.
2.
Lockwood S. Contemporary Issues in Women's Cancers. Sudbury: Jones and
Bartlett Publishers, LLC; 2009.
3.
Hartmann LC, Loprinzi CL. Mayo Clinic Guide to Women's Cancers. 1 ed.
Rochester: Mayo Clinic Health Information; 2005.
4.
Gangar EA. Gynaecological Nursing A Practical Guide. London: Harcourt
Publishers Limited; 2001.
5.
Cervical Screening in Australia 2005-2006. Canberra: Australian Institute of
Health and Welfare; 2008; Available from:
http://www.aihw.gov.au/publications/can/csa05-06/csa05-06.pdf.
6.
Hughes C. Cervical cancer: prevention, diagnosis, treatment and nursing
care. Nursing Standard. 2009;23(27):48-56; quiz 8.
7.
Farrell M. Smeltzer and Bare's textbook of medical-surgical nursing. 1st ed.
Broadway: Lippincott Williams & Wilkins Pty Ltd; 2005.
8.
Jefferies H. Cervical cancer 1: an overview of screening and diagnosis.
Nursing times. 2008;104(44):26-7.
9.
Harris P, Nargy S, Vardaxis N. Mosby's Dictionary of Medicine, Nursing &
Health Professions. Marrickville: Elsevier Australia; 2006.
10.
Teitelman A, Stringer M, Averbuch T, Witkoski A. Human papillomavirus,
current vaccines, and cervical cancer prevention. Journal of obstetric, gynecologic,
and neonatal nursing. 2009;38(1):69-80.
11.
National Cervical Screening Program. Australian Government Department of
Health and Aging; 2008; Available from:
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/c
ervical-about.
12.
Management Summary. Australian Government Department of Health and
Aging; 2008; Available from:
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/c
v-management-kit/$File/mgmt-summary.pdf.
13.
Mackay EV, Beischer NA, Pepperell RJ, Wood C. Illustrated Texted of
Gynaecology. 2 ed. Marrickville: W.B. Saunders; 1992.
14.
Gray S, Walzer T. New strategies for cervical cancer screening in
adolescents. Current opinion in pediatrics. 2004;16(4):344-9.
15.
Monga A. Gynaecology by Ten Teachers. 18 ed. London: Hodder Education;
2006.
16.
Moore-Higgs GJ, editor. Women and Cancer: A Gynecologic Oncology
Nursing Perspective. 2 ed. Sudbury: Jones and Bartlett Publishers; 2000.
17.
Clinical Guideline Section C, 13.2.1 Classification and Staging of Cervical
Cancers. Women and Newborn Health Service; n.d.; Available from:
http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/secti
onc/13/8501.pdf.
18.
Staging and grading of cervical cancer. Macmillan Cancer Support; 2006;
Available from:
http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Cervix/Symptomsd
iagnosis/Staginggrading.aspx.
19.
Jefferies H. Cervical cancer 2: treatment options and side-effects. Nursing
times. 2008;104(45):26-7.
20.
Nattress K. Cervical Cancer Lecture Notes. Gynaecology Oncology Nursing
Course 2008.
Department: Ward 6

Date Revised:
Page 29
21.
Grant P. Radical trachelectomy. The Australian & New Zealand journal of
obstetrics & gynaecology. 2006;46(5):372-4.
22.
Tanner P. Cancer Nurse Coordinator, Gynaecology. 2009.
23.
Department of Health WA. Gynaecologic Cancer Model of Care. Perth:
Cancer & Palliative Care Network, Department of Health, Western Australia; 2008.
24.
Sexuality for Women with Cancer: A guide for women with cancer, their
families and friends. The Cancer Council Western Australia.
25.
Nunns D, et al. The morbidity of surgery and adjuvant radiotherapy in the
management of endometrial carcinoma. International Journal of Gynaecological
Cancer. 2000;10(3):233-8.
26.
Wolf JK. Prevention and treatment of vaginal stenosis resulting from pelvic
radiation therapy. Community Oncology. 2006;3(10):665-8.
27.
Exercise for people living with cancer. The Cancer Council Western
Australia; 2007.
28.
The management of secondary lymphoedema: a guide for health
professionals. National Breast and Ovarian Cancer Centre; 2008.
29.
Likic I, Kadija S, Ladjevic N, Stefanovic A, Jeremic K, Petkovic S, et al.
Analysis of urologic complications after radical hysterectomy. American journal of
obstetrics and gynecology. 2008;199(6):644.e1-.e3.
30.
Burke C. Rectovaginal fistulas. Clinical Journal of Oncology Nursing.
2005;9(3):295-7.
31.
Palliative Medicine Specialist Service. Women and Newborn Health Service;
2004.
32.
Thorne D. Basic Analgesia Lecture Notes. 2009.

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Date Revised:
Page 30
DISCLAIMER
"The information presented in this publication is provided voluntarily as a public
service. The information and advice provided is made available in good faith and is
derived from sources believed to be reliable and accurate at the time of
publication. Whilst every attempt has been made to ensure accuracy of the
publication, the publication is a guide only and should not be seen as a substitute
for ensuring the information is current and up to date at the time of using this
package. The information is provided solely on the basis that readers will be
responsible for making their own assessment of the matters discussed herein, and
that they should verify the information and any representations or statements.
Enquiries regarding the information contained in this package may be directed to
the Clinical Development Nurse (Gynaecology) at King Edward Memorial Hospital.
(Ph: 9340 2699)
Produced by: Women and Newborn Health Service
November 2009

Department: Ward 6

Date Revised:
Page 31
EVALUATION OF LEARNING PACKAGE

FUNDAMENTALS OF CERVICAL CANCER
Thank you for completing this learning package. The authors would appreciate you
taking the time to complete this evaluation form so we may assess its effectiveness.
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1. How would you rate your knowledge

of cervical cancer before completing the
package?
2. How would you rate your knowledge
of cervical cancer after completing the
package?
3. How would you rate the layout of the
package, i.e. presentation, ease to
read, etc.
4. How do you feel the pre and post
tests assessed your knowledge?
5. How useful did you find the links to
other references and further learning
materials?
6. Overall, how would you rate the
package?
Do you have any comments or suggestions of how this package may be improved?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Name: ______________________________________________________
Designation: ____________________________
Workplace: _____________________________
Date package completed: __________________
Please return this evaluation to Natalie Williams, CDN, Ward 6, King Edward
Memorial Hospital.

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SELF DIRECTED LEARNING PACKAGE

Please see the Disclaimer at the end of this package

Fundamentals of Cervical Cancer

Catherine Adams Clinical Nurse

Reviewed by: Dr Yee Leung (Consultant & Head of Department,

This package remains the property of WNHS.

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

Identify the anatomy of the cervix;

SELF-ASSESSMENT REQUIREMENTS OF THE PACKAGE

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

WORKING THROUGH THE PACKAGE

Pre & Post Tests

Linking Theory to Clinical

Take Time Out or

For Additional Information

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

Date Published: November 2009

Figure 1. Anatomy of the Cervix

Figure 2. Transformation zone

Date Published: November 2009

HPV Viral infection, namely Human Papillomavirus (HPV) infection, is the

Early age of intercourse Sexual intercourse before 18 years of age increases

Smoking There is a link between cigarette smoking and a decrease in the

Immunosuppression Women who are taking immunosuppressive medications

Lower socio-economic status The incidence of cervical cancer is higher in

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

Figure 3. International Incident Patterns

Date Published: November 2009

CIN 2 Intermediate grade, affects half to two-thirds full thickness of the

Types of Cervical Cancer

Figure 4. Cell types at the transformation zone of the cervix

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

SIGNS & SYMPTOMS

Date Published: November 2009

Pap (Papanicolaou) Smear

Figure 5. Pap smear procedure

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

Figure 6. Colposcopy procedure

STAGING & GRADING

Date Published: November 2009

In addition to staging, cervical cancer is also classified by a Grading System. The

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

Figure 7. Cervical Cancer Stages I - IV

Date Published: November 2009

Figure 8. Cervical Cancer Early Stages I IIB

For further information on treatment for CIN (i.e. LLETZ) see

Date Published: November 2009

Name of Package: Fundamentals of Cervical Cancer

Date Published: November 2009

Figure 9. Radiation Therapy

Date Published: November 2009

Date Published: November 2009

At KEMH, a Multidisciplinary Team incorporating Allied Health also meet weekly on

Date Published: November 2009

Reduced vaginal size and vaginal stenosis