Cervical cancer early symptom

Help detect cervical cancer before it becomes difficult to treat. Here's how to encourage patients to get regular screening and to care for those with cancer.

EMMA NORMAN, 45, arrives for her check-up in a wheelchair pushed by her 19-year-old son. She's very thin, sallow, and clearly in pain. Because of a vesicovaginal fistula, she's incontinent, and she has a large amount of foul-smelling vaginal drainage from the necrotic tumor in her pelvis.

"I never thought I'd end up like this," she says as you help her onto the exam table.

Ms. Norman is one of the estimated 4,100 American women who will die of cervical cancer this year. Despite the availability of screening tests and early treatment, which have cut the death rates from cervical cancer in half since the early 1970s, cervical cancer remains the third most common gynecologic cancer in the United States. Worldwide, it's the most common cause of death from a gynecologic cancer. Nearly half of all women diagnosed with cervical cancer are diagnosed at a late stage, with either locally or regionally advanced disease that's harder to treat.

In this article, I'll discuss what you and your patients need to know about cervical cancer, including risk factors and screening tests, and explain how you can encourage women to take preventive action to protect their health.

From dysplasia to carcinoma

Cervical disease starts with dysplasia, or mildly atypical squamous cell changes that, if untreated, may progress to severe dysplasia (now called high-grade squamous intraepithelial lesions) and then to invasive carcinoma. One of the most common causes of dysplasia is sexual exposure to human papillomavirus (HPV)-more on this later. The two types of cervical cancer are squamous cell (accounting for 80% to 90% of cases) and adenocarcinomas (accounting for 10% to 20% of cases).

Early invasive and preinvasive disease is highly curable. But once cancer spreads to the lymphatic system or parametrial tissues adjacent to the cervix, treating it successfully becomes more difficult.

Smear campaign

Widespread cervical cytologic screening with the Papanicolaou (Pap) test (also called the Pap smear) has allowed clinicians to accurately identify treatable premalignant lesions. Screening at least once every 3 years improves the likelihood of detecting cervical abnormalities while they're easily treatable.

Regular screening and appropriate treatment has dramatically reduced the number of women who develop advanced cervical cancer in the United States. But despite the Pap test's widespread availability, about 50% of women whose cervical cancer is advanced at diagnosis have never had the test, and at least 10% haven't been screened in the 5 years before diagnosis.

With a screening tool as effective as the Pap test, why do we still see women like Ms. Norman? The answers are complex. Many women don't understand that the Pap test isn't automatically included in every pelvic examination. Most emergency department (ED) evaluations for pelvic pain don't include Pap testing, even if other tests are done to rule out sexually transmitted infections. Another area of misunderstanding involves the role of follow-up evaluation and treatment after an abnormal Pap test result: Many women don't know that appropriate care can prevent cervical cancer.

Poor women, the uninsured or under-insured, minority women, and the elderly are less likely to have regular Pap tests than young, middle-class white women. Outreach and educational efforts may be particularly useful in promoting screening among these groups.

Ms. Norman, like many women diagnosed with advanced cervical cancer, finished her childbearing before age 30 and had a tubal ligation. Because she wasn't experiencing gynecologic symptoms and didn't need birth control-and because her family didn't have health insurance-she didn't think she needed an annual pelvic examination.

Her cancer wasn't diagnosed until she came to the ED with heavy vaginal bleeding and lumbosacral back pain. Other clinical manifestations of cervical cancer may include yellowish vaginal discharge, abnormal vaginal bleeding or postcoital spotting, genital warts, and sometimes urinary or bowel symptoms. However, some patients are asymptomatic until the cancer is locally advanced.

By the time Ms. Norman came to the ED, the tumor had spread from her cervix into adjacent tissues, eroding through the bladder wall into the vagina, creating a fistula. The tumor extended into the pelvic sidewall, creating bone pain and obstructing a ureter. She hadn't had a Pap test in more than 8 years, and she had many of the risk factors for cervical cancer.

Sexual exposure to HPV, which is present in an estimated 93% of cervical neoplasias, is a wellestablished risk factor. A woman's likelihood of exposure to HPV increases with the number of lifetime sexual partners and is also associated with low socioeconomic status, low educational level, early onset of intercourse, and use of oral contraceptives without barrier protection. Condoms prevent transmission of most sexually transmitted diseases and may prevent some (though not all) HPV infections. Exposure to herpes simplex virus, type 2, is another risk factor.

Nursing research into the health effects of intimate partner abuse has indicated that women in abusive relationships may face a higher risk of sexually transmitted diseases, partly due to forced sexual activity and partly due to the controlling behavior of an abusive partner: Abused women may be physically or psychologically prevented from seeking reproductive health care. As a nurse, you may be in the best position to offer support and referral to women who are victims of abuse.

A woman with a history of childhood sexual abuse may avoid regular gynecologic care, including Pap test screening and follow-up procedures, because being examined may trigger memories of abuse or be physically painful. But avoiding screening and care increases her risk of developing cervical cancer. Unfortunately, a history of childhood sexual abuse also increases a woman's risk of exposure to sexually transmitted infections that contribute to the development of cervical cancer. If you participate in gynecologic exams, you can help your patient by responding to her verbal and nonverbal cues, explaining the procedure, maintaining a reassuring presence through the exam, and teaching her how regular screening and follow-up protects her health.

Evaluating abnormalities

The Pap test, whether based on conventional (glass slide and fixative) or liquid-based (ThinPrep) cytology, is a screening test, not a diagnostic procedure. Although statistically, most low-grade lesions resolve without treatment, any abnormal Pap test result requires follow-up because this test alone can't rule out high-grade squamous intraepithelial lesions.

If testing reveals cervical cytologie abnormalities, according to the 2001 Consensus Guidelines for the Management of Women with Cervical Cytological Abnormalities, follow-up tests are based on the type of abnormality detected.

Under the current Pap test reporting system, atypical cells are reported either as of "undetermined significance" or "can't rule out high-grade squamous intraepithelial lesion."

Women with atypical cells of undetermined significance should be followed with reflex HPV DNA testing, performed on the original liquid-based Pap sample, if available; repeat cervical cytology at 4to 6-month intervals until they have two consecutive normal Pap tests; or colposcopy.

Women whose Pap tests show low-grade or high-grade squamous intraepithelial lesions, or atypical glandular cells, should have colposcopy and endocervical sampling.

Reflex HPV DNA testing lets the patient know if she's at risk for high-grade cervical dysplasia and needs further evaluation or is lowrisk and can be followed with a repeat Pap test in 12 months.

To perform a colposcopy, a physician or trained advanced practice nurse looks at the surface of the cervix through a low-power microscope, which makes areas of tissue abnormality easier to identify. Biopsies are taken of any abnormalities.

For more on the American Cancer Society (ACS) guideline for cervical cancer screening, see Following the Screening Guideline.

Staging guides treatment

Treatment for invasive cervical cancer depends on the stage of disease and may include surgery to remove the cancer, chemotherapy, and radiation. Staging is based on clinical findings from pelvic and abdominal computed tomography scans. For more on staging and treatment, see Determining Therapy for Cervical Cancer.