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CANCER OF THE UTERUS (Uterine Cancer) – Causes and Risk Factors, Stages, Diagnostic Evaluation, Management and Prevention (Nursing Intervention) 

CANCER OF THE UTERUS (Uterine Cancer) – Causes and Risk Factors, Stages, Diagnostic Evaluation, Management and Prevention (Nursing Intervention)

CANCER OF THE UTERUS (Uterine Cancer) – Causes and Risk Factors, Stages, Diagnostic Evaluation, Management and Prevention (Nursing Intervention)

 
Uterine cancer or endometrial cancer is the most common gynecologic cancer. It develops in the body of the uterus, or womb, which is a hollow organ located in the lower abdomen. Most endometrial cancers are adenocarcinomas (cancers that begin in cells that make and release mucus and other fluids). Endometrial cancer is orginate in the inner lining (endometrium) of the uterus, accounts for about 90% of uterine cancers. Uterine sarcoma originates in an outer layer of muscle tissue (myometrium) and accounts for less than 10% of cases. Incidence of uterine cancer increases after menopause and approximately 75% of cases are diagnosed in postmenopausal patients. The average age at diagnosis is about 60 years.

CAUSES AND RISK FACTORS

The cause of uterine cancer is unknown.

  • Chronic exposure to estrogen: Increases the risk for developing the disease and estrogen often affects tumor growth. The following factors increase estrogen exposure: Early menarche (beginning menstruation before age 12), hormone replacement therapy with exogenous estrogen, late menopause (after age 52), nulliparity (having never given birth) or low parity, irregular ovulation and presence of an estrogen-secreting tumor (e.g., some types of breast cancer).
  • Endometrial hyperplasia: The risk of uterine cancer is higher if women have endometrial hyperplasia. About one-third of patients with hyperplasia develop endometrial cancer.
  • Obesity and related conditions: The body makes some of its estrogen in fatty tissue. High levels of estrogen may be the reason that obese women have an increased risk of developing uterine cancer. The risk of this disease is also higher in women with diabetes or high blood pressure.
  • Tamoxifen: Women taking the drug tamoxifen to prevent or treat breast cancer have an increased risk of uterine cancer. This risk appears to be related to the estrogen-like effect of this drug on the uterus.
  • A high fat diet: This type of diet may add to your risk of endometrial cancer by promoting obesity. Or fatty foods may directly affect estrogen metabolism, further increasing a woman’s risk of endometrial cancer.
  • Diabetes: Endometrial cancer is more common in women with diabetes, possibly because obesity and type II diabetes often go hand in hand. However, even women with diabetes who aren’t overweight have a greater risk of endometrial cancer.


 

Other risk factors include the following:

  • Age (more common after age 50)
  • Family history of uterine cancer
  • Personal history of breast, colorectal, or ovarian cancer
  • Prior pelvic radiation therapy
  • Race (white women are more likely than African-American women to get uterine cancer)


 

CLINICAL MANIFESTATIONS

Early uterine cancer usually is asymptomatic. Most cases of endometrial cancer develop in postmenopausal women, whose periods have stopped. Abnormal vaginal bleeding, which is the most common symptom, may also result from a condition called dysfunctional uterine bleeding (DUB).

Other symptoms of uterine cancer include the following:

  • Any bleeding after menopause
  • Prolonged periods or bleeding between periods
  • An abnormal, non bloody discharge from vagina
  • Painful or difficult urination
  • Pelvic pain
  • Pain during intercourse


 

Advanced uterine cancer may cause weight loss, loss of appetite, and changes in bladder and bowel habits.

 

STAGING OF UTERINE CANCER

The main goal of staging cancer is to determine the extent of the disease. These are the main features of each stage of the disease:

STAGE I: The cancer is only in the body of the uterus. It is not in the cervix

STAGE II: The cancer is only in the body of the uterus. It is not in the cervix.

STAGE III: The cancer has spread outside the uterus, but not outside the pelvis (and not to the bladder or rectum). Lymph nodes in the pelvis may contain cancer cells.

STAGE IV: The cancer has spread into the bladder or rectum. Or it has spread beyond the pelvis to other body parts

 

DIAGNOSTIC EVALUATIONS

  • Pelvic exam: A women has a pelvic exam to check the vagina, uterus, bladder, and rectum. The doctor feels these organs for any lumps or changes in their shape or size. To see the upper part of the vagina and the cervix, the doctor inserts and instrument called a speculum into the vagina.
  • Pap test: Doctor takes a sample of cells from the cervix, the lower, narrower portion of the uterus that opens into your vagina. Because endometrial cancer begins inside your uterus, it’s rarely detectable by a Pap test.
  • Endometrial biopsy: In most cases, endometrial biopsy is used to diagnosis uterine cancer. This outpatient procedure involves inserting a narrow tube into the uterus through the vagina and suctioning out a small amount of tissue from several areas of the uterine wall. The tissue is examined under a microscope and evaluated for cancerous or precancerous abnormalities. The procedure usually takes minutes to perform and provides an accurate diagnosis in 90% of cases.
  • Dilation and Curettage: A dilatation and curettage (D and C) is performed to diagnose the disease. This procedure involves dilating (widening) the cervix and inserting an instrument called a curette into the uterus through the vagina. The curette is used to scrape the uterine wall and collect tissue. In suction curettage, suction is applied through a narrow tube to remove the tissue sample. D and C is an outpatient procedure that takes about an hour and requires general anesthesia. A pathologist examines the tissues to check for cancer cells, hyperplasia, and other conditions.
  • Exploratory laparotomy: Exploratory laparotomy may be used to stage uterine cancer. Two methods for this procedure include endoscopic laparotomy and open laparotomy. In endoscopic laparotomy, a lighted, flexible instrument (called an endoscope) is introduced into the abdomen through a small incision and used to examine organs and lymph nodes in the peritoneal cavity. Abnormal tissue is removed for biopsy using tiny instruments that are passed through the endoscope. In open laparotomy, the peritoneal cavity is explored through an abdominal incision.
  • Imaging tests: Patients with certain medical conditions (e.g., severe high blood pressure, obesity, diabetes, metastatic cancer) may be unable to safely tolerate anesthesia. In these patients, imaging tests such as MRI scan, CT scan, transabdominal ultrasound, and transvaginal ultrasound may be used to diagnose cancer of the uterus.


MANAGEMENT

Treatment for uterine cancer depends on the stage of the disease and the overall health of the patient. Removal of the tumor (surgical resection) is the primary treatment. Radiation therapy, hormone therapy, and/or chemotherapy may be used as adjuvant treatment in patients with metastatic or recurrent disease.

  1. Surgical Treatment: Surgery is the most common treatment for endometrial cancer. Most doctors recommend either the surgical removal of the uterus alone (hysterectomy) or, more likely, the surgical removal of the uterus, fallopian tubes and ovaries (hysterectomy with bilateral salpingo-oophorectomy). Lymph nodes in the area should also be removed during surgery along with other tissue samples.
  2. Radiation Therapy: Some women with stage I, II or III uterine cancer need both radiation therapy and surgery. They may have radiation before surgery to shrink the tumor or after surgery to destroy any cancer cells that remain in the area. Also, the doctor may suggest radiation treatments for the small number of women who cannot have surgery. Doctors use both external and internal radiation therapies to treat uterine cancer
  3. Hormone Therapy: Hormone therapy may be used to treat endometrial cancer. Some uterine tumors contain certain proteins, called hormone receptors, which attract and bind to estrogen and use this hormone to grow. If the cancer has spread to other parts of body, synthetic progestin, a form of the hormone progesterone, may stop it from growing. Another hormone therapy option is gonadotropin-releasing hormone agonists. These drugs can lower estrogen levels in premenopausal women.
  4. Chemotherapy: Chemotherapy may be used in addition to surgery to treat metastatic endometrial cancer and to prevent recurrent disease. Generally, women with stage III or stage IV endometrial cancer will be offered chemotherapy as part of their treatment regimen. Drugs may be administered orally or intravenously. The following drugs are used to treat endometrial cancer: Carboplatin, Cisplatin, Doxorubicin, Cyclophosphamide and Paclitaxel (Taxol).


PREVENTION

Although most cases of endometrial cancer aren’t preventable, certain factors can lower risk of developing the disease. These include:

  1. Taking hormone therapy (HT) with progestin: Estrogen stimulates growth of the endometrium. Replacing estrogen alone after menopause may increase risk for endometrial cancer. Taking synthetic progestin, a form of the hormone progesterone, with estrogen causes the lining of the uterus to shed. This kind of combination hormone therapy lowers risk
  2. A history of using birth control Pills: Use of oral contraceptives can reduce endometrial cancer risk even as long as 10 years after stop taking them. The risk is lowest in women who take oral contraceptives for many years.
  3. Maintaining a healthy weight: Obesity is one of the most significant risk factors for the development of endometrial cancer. You can help prevent endometrial cancer by maintaining a healthy weight. Excess fat tissue can increase levels of estrogen in body, which increases risk of endometrial cancer.
  4. Exercise: Regular exercise can have a dramatic effect on risk of endometrial cancer. Women who engage in exercise every day have half the risk of endometrial cancer compared with women who don’t exercise, according to the American Cancer Society.​ 


NURSING MANAGEMENT: AFTER HYSTERECTOMY

Preoperative Nursing Interventions

  1. Assist patient to seek information on stage of cancer and treatment options. Explain about side effects of radiation and chemotherapy
  2. Give explanations to the patient about physical preparation and procedures that are performed pre and postoperatively.
  3. Administer analgesics and tell the patient that heavy lifting, strenuous exercise, and sexual intercourse may increase pain.
  4. Encourage small, frequent, bland meals/liquid nutritional supplements as able.
  5. Preparing Skin for Surgery: Skin  preparation may include cleansing the lower abdomen, inguinal areas, upper thighs, and vulva with a detergent germicide for several days before the surgical procedure.


 

Postoperative Nursing Interventions

  1. Observe the patient for sign of shock. Check wound dressing regularly. If there is a wound drain checks amount and type of drainage regularly
  2. Hemorrhage may occur within 24 hours, the nurse should observe for signs of internal and external bleeding. Hemorrhage is more common after vaginal hysterectomy.
  3. Give appropriate analgesic drugs as prescribed. Patient may have pain related to surgical procedure and discomfort from abdominal distention.
  4. Encourage frequent changes of position in bed. Activity decreases pain by increasing circulation and reducing muscle tension
  5. Monitor stool characteristics and frequency. Restrict oral fluid and food until peristalsis resumes
  6. Ensure adequate hydration with intravenous fluids. Hydration will promote a soft stool
  7. Encourage the patient to ambulate as soon as possible. Early ambulation promotes peristalsis and promotes venous return
  8. Bowel dysfunction related to surgery may cause nausea and anorexia. Administer antiemetics as prescribed when require for nausea and vomiting
  9. Measure and record urinary output until patient void sufficiently. Urinary difficulties are common due to proximity of surgical site of the bladder
  10. Patient may require catheterization if unable to pass urine or unable to empty bladder completely. Distended bladder may pull on newly sutured pelvic tissues causing discomfort and hematoma.
  11. Monitor temperature, take regular urine specimens for culture and check wound for signs of inflammation or for any abnormal discharge. Wound infection and urinary tract infection are the most common infections after hysterectomy.
  12. Encourage that patient has antiembolitic stockings. Encourage leg exercises and early mobilization. Thrombosis is common complication after gynecologic surgery. This may be due to the site of surgery, with its interruption to pelvic venous return.​