uterine cancer

Gynecology Any cancer that arises in the uterus–eg, cervical CA, choriocarcinoma, endometrial CA, leiomyosarcoma, mesodermal mixed tumor. See Endometrial CA.

Uterine Cancer

DRG Category:	740
Mean LOS:	4.2 days
Description:	SURGICAL: Uterine and Adnexa Procedure for Non-Ovarian/Adnexal Malignancy With CC
DRG Category:	755
Mean LOS:	5 days
Description:	MEDICAL: Malignancy, Female Reproductive System With CC

Approximately 50,000 women in the United States are diagnosed with uterine cancer each year, and in 2013, 8,190 women died from the disease. Uterine cancer most commonly occurs in the endometrium, the mucous membrane that lines the inner surface of the uterus. Endometrial cancer, specifically adenocarcinoma (involving the glands), accounts for more than 95% of the diagnosed cases of uterine cancer. There has been an increase noted in the number of women with endometrial cancer, partly owing to women living longer and more accurate reporting. Endometrial cancer is the fourth-most common cause of cancer in women, ranking behind breast, colorectal, and lung cancer. It is the most common neoplasm of the pelvic region and reproductive system of the female, and it occurs in 1 in 100 women in the United States. Other uterine tumors include adenocarcinoma with squamous metaplasia (previously referred to as adenoacanthoma), endometrial stromal sarcomas, and leiomyosarcomas.

Endometrial cancer can infiltrate the myometrium, resulting in an increased thickness of the uterine wall, and it can eventually infiltrate the serosa and move into the pelvic cavity and lymph nodes. It can also spread by direct extension along the endometrium into the cervical canal; pass through the fallopian tubes to the ovaries, broad ligaments, and peritoneal cavity; or move via the bloodstream and lymphatics to other areas of the body. It is a slow-growing cancer, taking 5 or more years to develop from hyperplasia to adenocarcinoma. Endometrial cancer is very responsive to treatment, provided it is detected early. Prognosis depends on the stage, uterine signs, and lymph node involvement.

Causes

The exact cause of uterine cancer is not known, although it is considered to be dependent on endogenous hormonal levels for growth. Risk factors associated with the development of uterine adenocarcinoma include age, genetic and familial factors, early menarche (before age 12), late menopause (after 52 years), hypertension, nulliparity, unopposed estrogen hormonal replacement therapy, pelvic irradiation, polycystic ovarian disease, obesity, and diabetes mellitus. Leiomyosarcomas are more common among African Americans. Women who have used oral fertility medications, specifically clomiphene, may have an increased risk of uterine cancer.

Genetic considerations

Women with hereditary nonpolyposis colorectal cancer (HNPCC) have a risk of uterine cancer that is 50% higher than that of the general population. Uterine cancer is so common in this population that some families with HNPCC gene variants will have only cases of uterine cancer and no colon cancer. It is estimated that 1 in 10 women with uterine cancer may have a genetic predisposition. Genetic risk is higher if uterine cancer occurs before age 50; occurs along with another cancer, such as colon, ovarian, stomach or bile duct; occurs when there is a history of colon polyps before age 40; or occurs when the patient has family members with other gastrointestinal cancers or polyps. Mutations in TP53, which causes Li-Fraumeni syndrome, also increases the incidence of uterine cancer. However, soft tissue sarcomas and osteosarcomas, breast cancer, brain tumors, leukemia, and adrenocortical carcinoma are more common in Li-Fraumeni syndrome.

Gender, ethnic/racial, and life span considerations

Uterine cancer occurs primarily in middle-aged and elderly women who are postmenopausal, with a peak incidence occurring between ages 58 and 60. Only 10% of the cases occur in women under age 50, and it is rare in women under 30. With endometrial cancer, mortality is higher in women with black/African American ancestry than in women with white/European ancestry, with a mortality rate of 7 deaths per 100,000 individuals in black women and 4 deaths per 100,000 individuals in white women. Differences in mortality are thought to be related to late diagnosis for black women due to problems with access to care.

Global health considerations

The global incidence of uterine cancer is 6.5 per 100,000 females per year. The incidence is 10 times higher in developed than in developing countries, in part because of higher rates of obesity and lower parity in developed countries.

Assessment

History

Establish a history of risk factors. The major initial symptom of endometrial cancer occurring in 85% of women is abnormal, painless vaginal bleeding, either menometrorrhagia (prolonged, excessive uterine bleeding and more frequent than normal) or postmenopausal. A mucoid and watery discharge may be noted several weeks to months before this bleeding. Postmenopausal women may report bleeding that began a year or more after menses stopped. A mucosanguineous, odorous vaginal discharge is noted if metastases to the vagina has occurred. Younger women may have spotting and prolonged, heavy menses.

Inquire about pain, fever, and bowel/bladder dysfunction, which are late symptoms of uterine cancer. Assess the use and effectiveness of any analgesics for pain relief and also the location, onset, duration, and intensity of the pain.

Physical examination

Conduct a general physical and gynecological examination. The woman should be directed to not douche or bathe for 24 hours before the examination so that tissue is not washed away. Inspection of any bleeding or vaginal discharge is imperative. The characteristics and amount of bleeding should be noted. Upon palpation, the uterus will feel enlarged and may reveal masses.

Psychosocial

Women with the disease often exhibit depression and anger, especially if they are a nulligravida. Therefore, a thorough assessment of the woman’s perception of the disease process and her coping mechanisms is required. The family should also be included in the assessment to examine the extent of support they can provide for the patient. Family anger, ineffective coping, and role disturbances may interfere with family functioning and need careful monitoring.

Diagnostic highlights

General Comments: Several diagnostic tests may be done to confirm the diagnosis and to check for metastases.

Test	Normal Result	Abnormality With Condition	Explanation
Fractional dilation and curettage of the uterus	No malignant cells found	Malignant cells found	Obtain specimen of endometrium and endocervix for pathological examination
Papanicolaou examination (Pap smear)	No abnormality or atypical cells noted	High-class/grade cytological results	Initial screening; can detect approximately 50% of cases of uterine cancer

Other Tests: CA-125 blood test is used for surveillance for advanced uterine cancer. Other tests include sonography, sonohysterography, hysteroscopy, chest x-ray, intravenous (IV) pyelography, cystoscopy, proctoscopy, computed tomography scan, and magnetic resonance imaging.

Primary nursing diagnosis

Diagnosis

Knowledge deficit related to treatment procedures, treatment regimens, medications, and disease process

Outcomes

Knowledge: Treatment procedures; Knowledge: Treatment regimens; Knowledge: Medications; Knowledge: Disease process

Interventions

Teaching: Disease process; Teaching: Prescribed medication; Teaching: Procedure/treatment; Teaching: Preoperative

Planning and implementation

Collaborative

surgical.

If uterine cancer is detected early, the treatment of choice is surgery. A total abdominal hysterectomy (TAH) with removal of the fallopian tubes and ovaries, bilateral salpingo-oophrectomy (BSO), is generally performed. Common complications after a hysterectomy are hemorrhage, infection, and thromboembolitic disease. Premenopausal women who have a BSO become sterile and experience menopause. Hormone replacement therapy may be warranted and is appropriate. In a total pelvic exenteration (evisceration or removal of the contents of a cavity), the surgeon removes all pelvic organs, including the bladder, rectum, and vagina. This procedure is performed if the disease is contained in the areas without metastasis. If the lymph nodes are involved, this procedure is usually not curative.

radiation.

Radiation therapy may also be given in combination with the surgery (before or after), or it may be used alone depending on the staging of the disease, whether the tumor is not well differentiated, or whether the carcinoma is extensive. Radiation may be the treatment of choice for the very elderly woman with an advanced stage of endometrial cancer for whom surgery would not improve quality of life. With radiation, the possible complications are hemorrhage, cystitis, urethral stricture, rectal ulceration, or proctitis.

Intracavity radiation (brachytherapy) or external radiation therapy may be given 6 weeks before surgery to limit recurrence or to improve the chance of survival. An internal radiation device may be implanted during surgery (preloaded) or at the patient’s bedside (afterloaded). If the device is inserted during the surgical procedure, the postoperative management needs to include radiation precautions. Provide a private room for the patient and follow the key principle to protect against radiation exposure: distance, time, and shielding. The greater the distance from the radiation source, the less exposure to ionizing rays. The less time spent providing care, the less radiation exposure. The source of radiation determines if lead shields are necessary to provide care. All healthcare workers coming in contact with a “hot” patient (a patient with an internal radiation implant) need to monitor their exposure with a monitoring device such as a film badge. Nursing care of patients with radiation implants is detailed in Table 1.

Nursing Care of Patients with Radiation Implants

Table 1. Nursing Care of Patients with Radiation Implants
STRATEGY	RATIONALE
Place patient in a private room	A private room limits radiation exposure for guests, other patients, and staff
Identify the difference between a sealed and an unsealed source: Sealed sources of internal radiation are completely enclosed by nonradioactive material; the radioactive isotope cannot circulate through the patient’s body and cannot contaminate urine, blood, feces, or other secretions Unsealed sources are colloid suspensions that come in direct contact with body tissues and are administered IV or PO or instilled into a body cavity; the isotope may be excreted into any body fluid
Dispose of all wastes according to hospital protocol if the patient has an unsealed source; teach the patient to flush the toilet several times after voiding if appropriate; if the patient has a discharge, discard the linen according to hospital standards	Decrease the risk of radiation exposure to those other than the patient
Plan care so as to spend a minimal amount of time in the room. Do not spend more than 30 min in the room per shift. Strategies to maximize time: Fix food trays outside the room Work as quickly as possible Take a prepared bedroll into the room for linen changes Do not care for more than one patient per shift with radiation implants Reassign pregnant staff to other assignments Notify the patient that young children and pregnant family or friends should not visit until after the implant is removed	Limits radiation exposure
Use distance between the nurse and the patient during caregiving activities (note: social isolation may result): If patient can be out of bed, have her sit as far as possible from the bed during linen changes Provide care standing at the patient’s shoulder, where exposure is low; this technique also uses the patient’s body as a shield	Limits radiation exposure
Encourage the woman to limit body movements while the source is in place; keep all personal items within easy reach to limit stretching or straining; limit lower extremity exercises; provide diversionary activity such as reading, television, radio, tapes	Decreases the risk of dislodging the implant
Wear a radiation monitoring device at all times when in the room	Records exposure
Mark the room with radiation safety signs	Limits the risk of accidental exposure
Keep long-handled forceps and a lead-lined container on the unit at all times	If the implant is accidentally dislodged, use the forceps to place it in the container and notify radiation safety and the physician immediately
Request that radiation safety monitor all unit procedures for compliance	Limits the risk of accidental exposure

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Doxorubicin; cisplatin; carboplatin; ifosfamide; gemcitabine	Given in combination	Antineoplastic	Response rate of 15%
Paclitaxel (Taxol)	Depends on patient tolerance and condition	Antineoplastic	Response rate of 35%; premedicate with corticosteroids, diphenhydramine, and H2 antagonists
Acetaminophen; NSAIDs; opioids; combination	Depends on the drug and patient condition and tolerance	Analgesics	Analgesics used are determined by the severity of pain

Other Drugs: As an experimental therapy, the use of tamoxifen (Nolvadex) to treat advanced or recurrent endometrial cancer is being investigated.

Independent

The major emphasis is prevention, either primary by reduction of risk factors or secondary by early detection. Encourage women to seek regular medical checkups, which should include gynecologic examination. Discuss risk factors associated with the development of endometrial cancer, particularly as they apply or do not apply to the particular woman. Encourage the older menopausal woman to continue with regular examinations. If the woman is bleeding heavily, monitor her closely for signs of dehydration and shock (dry mucous membranes, rapid and thready pulses, delayed capillary refill, restlessness, and mental status changes). Encourage her to drink liberal amounts of fluids and have the equipment available for IV hydration if necessary. A balanced diet promotes wound healing and maintains good skin integrity.

Patients require careful instruction before radiation therapy or surgery. Explain the procedures carefully and notify the patient what to expect after the procedure. For surgical candidates, teach coughing and deep-breathing exercises. Fit the patient with antiembolism stockings. If the patient is premenopausal, explain that removal of her ovaries induces menopause. Unless she undergoes a total pelvic exenteration, her vagina is intact and sexual intercourse remains possible. During external radiation therapy, the patient needs to know the expected side effects (diarrhea, skin irritation) and the importance of adequate rest and nutrition. Explain that she should not remove ink markings on the skin because they direct the location for radiation. If a preloaded radiation implant is used, the patient has a preoperative hospital stay that includes bowel preparation, douches, an indwelling urinary catheter, and diet restrictions the day before surgery.

If the woman has pain from either the surgical procedure or the disease process, teach her pain-relief techniques such as imagery and deep breathing. Encourage her to express her anger and feelings without fear of being judged. Note that surgery and radiation may profoundly affect the patient’s and partner’s sexuality. Answer any questions honestly, provide information on alternatives to traditional sexual intercourse if appropriate, and encourage the couple to seek counseling if needed. If the woman’s support systems and coping mechanisms are insufficient to meet her needs, help her find others. Provide a list of support groups that may be helpful.

Evidence-Based Practice and Health Policy

Kasuya, G., Ogawa, K., Iraha, S., Nagai, Y., Shiraishi, M., Hirakawa, M., …Murayama, S. (2011). Severe late complications in patients with uterine cancer treated with postoperative radiotherapy. Anticancer Research, 31(10), 3527–3533.

In a retrospective analysis of 228 patients who underwent radical hysterectomy and postoperative external beam radiotherapy for treatment of uterine cancer, 8.3% developed severe radiation enterocolitis during a median follow-up period of 81.7 months (range, 1 to 273 months).
A history of smoking increased the risk of enterocolitis by 3.62 times among patients in this sample (95% CI, 1.32 to 10; p = 0.013).

Documentation guidelines

Physiological response: Amount and characteristics of any vaginal bleeding or discharge, vital signs, intake and output if appropriate, weight loss or gain, sleep patterns
Emotional response: Signs of stress, ability to cope, degree of depression, relationship with partner and significant others
Comfort: Location, onset, duration, and intensity of pain; effectiveness of analgesics and pain-reducing techniques

Discharge and home healthcare guidelines

prevention.

Teach the need for regular gynecological examinations even though the patient has had a hysterectomy. Teach the patient to report any abnormal vaginal bleeding to the healthcare provider. The woman who has had a TAH with BSO is at risk for developing osteoporosis. Recommend a daily intake of up to 1,500 mg of calcium through diet and supplements. Recommend vitamin D supplements to enable the body to use the calcium. Stress the need for regular exercise, particularly weight-bearing exercise. Discuss the exercise schedule and type with the patient in light of her treatment and expected recovery time.

medications.

Ensure that the patient understands the dosage, route, action, and side effects of any medication she is to take at home. Note that to monitor her response, some of the medications require her to have routine laboratory tests following discharge from the hospital.

postoperative.

Discuss any incisional care. Encourage the patient to notify the surgeon for any unexpected wound discharge, bleeding, poor healing, or odor. Teach the patient to avoid heavy lifting, sexual intercourse, and driving until the surgeon recommends resumption.

radiation.

To decrease bulk, teach the patient to maintain a diet high in protein and carbohydrates and low in residue. If diarrhea remains a problem, instruct the patient to notify the physician or clinic because antidiarrheal agents can be prescribed. Encourage the patient to limit her exposure to others with colds because radiation tends to decrease the ability to fight infections. To decrease skin irritation, encourage the patient to wear loose-fitting clothing and avoid using heating pads, rubbing alcohol, and irritating skin preparations.

follow-up care.

Teach the patient appropriate self-care for her specific treatment. Teach the patient to be able to identify where she can obtain assistance should postoperative or posttreatment complications occur. Make sure the significant others are aware of the expectations of a normal convalescence and whom to call should concerns arise.

Patient discussion about uterine cancer

Q. Is it safe to have sex with a woman with cancer of the uterus? My 45-years old wife was told she have cancer in the uterus, and will have an operation soon. Meanwhile, should we use a condom during sex? Can the tumor pass from her to me (like AIDS or HPV)?A. unless the cancer has lots of bleeding, you don't need to use condoms.
but if your wife would undergo an operation, maybe you need to be off-of-that-sex 1-2 days prior to operation day, just to make sure there's no super infection that will bother the operation plan.

More discussions about uterine cancer