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Thursday, 17 November 2011

REPRODUCTIVE CANCERS: NURSING RESEARCH

REPRODUCTIVE CANCERS


 


Globally, women are increasingly reported to be dying from reproductive cancers. The reproductive cancers included breast, ovarian, endometrial, uterine and cervical cancers among others. There are more than 100 different types of cancer. The most common causes of cancer deaths are not necessarily the most frequently occurring cancers.


Cancer is a disease of the body’s cells. Normally cells grow and multiply in an orderly way. Occasionally, however, if something causes a mistake to occur in the cells’ genetic blueprints, they may behave abnormally and spread out of control. Cancer is caused in all or almost all instances by mutation or by some other abnormal activation of cellular genes that control cell growth and cell mitosis. The abnormal genes are called oncogenes. As many as 100 different oncogenes have been discovered. Also present in all cells are actioncogenes, which suppress the activation of specific oncogenes. Therefore, loss of or inactivation of actioncogenes allows activation of oncogenes that lead to cancer ( 2000).


As mutant cells grow and divide a mass of abnormal cells or tumor is formed. In some cases, the cells do not form a lump or tumor. Some tumors grow but do not spread beyond the immediate area in which they arise. These are called benign tumors, and are not cancerous. Other tumors can spread into surrounding areas, or to different parts of the body. These are known as malignant tumors commonly referred to as cancers.


Cancer cells can break away from the mass (or tumor) and travel via the bloodstream or lymphatic system to different parts of the body and form new masses there. These cells can settle in other parts of the body to form a secondary cancer or metastasis.


Cancers arising from epithelial cells which line the body’s internal and external surfaces are called carcinomas, while leukemias are cancers of blood-forming organs, lymphomas from reticulo-endothelial lymph node organs, and sarcomas from connective tissues.


Why do cancer cells kill? The answer to this question is usually simple. Cancer tissue competes with normal tissues for nutrients. Because cancer cells continue to proliferate indefinitely, their number multiplying day by day, one can readily understand that the cancer cells soon demand essentially all the nutrition available to the body or to an essential part of the body. As a result, normal tissues gradually suffer nutritive death (2000).


            According to the World Cancer Report of the World Health Organization, released April 3, 2004, Lung cancer is the most common cancer worldwide, accounting for 1.2 million new cases annually; followed by cancer of the breast, just over 1 million cases; colorectal, 940,000; stomach, 870,000; liver, 560,000; cervical, 470,000; esophageal, 410,000; head and neck, 390,000; bladder, 330,000; malignant non-Hodgkin lymphomas, 290,000; leukemia, 250,000; prostate and testicular, 250,000; pancreatic, 216,000; ovarian, 190,000; kidney, 190,000; endometrial, 188,000; nervous system, 175,000; melanoma, 133,000; thyroid, 123,000; pharynx, 65,000; and Hodgkin disease, 62,000 cases.


            In 2000, there were more than 4.7 million cases of cancer in women worldwide, 54% of which occurred in less developed countries. Gynecologic tumors, including cancer of the endometrium, ovary, vulva, vagina, placenta and adnexa, accounted for 8% of all female primary tumors worldwide and 45% of all genital cancers.


Breast cancer is the second most common cancer in the world and the most common cancer in women, accounting for 18% of all female malignancies ( 2003). The annual mortality rates range from 27/100,000 women in northern Europe to 4/100,000 in Asia.


In the US, breast cancer is the second leading cause of cancer deaths. There were 192,000 breast cancer cases and 40,000 deaths reported in 2001. The incidence rate of breast cancer-defined as the number of new cases in a given year per 100,000 persons – rose dramatically in the years between 1940 and 1990. Between 1990 and 1997, White women reported the highest incidence of breast cancer (114 per 100,000) and African American women reported the second highest incidence rate (100 per 100,000). For most American women, the mortality rate of breast cancer has steadily declined. However, for older African American women-those 75 years of age and above-the mortality rate has increased since 1990.


            Asian women have traditionally had low breast cancer rates. But at present, invasive breast cancer cases have grown significantly among Japanese and Chinese women, and especially among South Asians and Koreans. Researchers suspect that Asians’ breast cancer rates have risen as immigrant women have adopted elements of a Western lifestyle, especially having fewer children and delaying having children until later in life.


Breast cancer is the most common cause of cancer-related death in Australian women. One out of eleven women is diagnosed with breast cancer before the age of 75. A total of 11,791 women are diagnosed with breast cancer and 2,594 women died from breast cancer in Australia in 2001.


Cancer of the breast is generally not painful, though a vague discomfort may sometimes be present. The great majority of breast cancers appear as a slowly growing painless mass. Among the physical signs to look for are a retracted nipple, bleeding from the nipple, distorted areola or breast contour, skin dimpling over the lesion, attachment of the mass to surrounding tissues including the underlying fascia and overlying skin, edema of the skin of the breast with ”pitted like an orange skin” appearance, and enlarged axillary or supraclavicular lymph nodes.


Although one in eight women will eventually develop breast cancer, it is important to note that this is a cumulative lifetime risk that increases with age. More than three fourths of breast cancer cases occur in women 50 years or older; more than half in women older than the age 65. For women between the ages of 35 and 55 without major risk factors, the chance of developing breast cancer is approximately 2.5% (2003). Breast cancer risk factors include family history, menstrual history, pregnancy and breast conditions and diseases.


            Breast cancer is sometimes found in women who are pregnant or have just given birth. In women who are pregnant or who have just given birth, breast cancer occurs most often between the ages of 32 and 38. Breast cancer occurs about once in every 3,000 pregnancies.


            The best method for early clinical detection of breast cancer is mammography. BreastScreen Australia is the national mammographic screening program of Australia. It provides free screening mammograms for women aged 50-69, with the aim of reducing deaths from breast cancer in this target group.


A woman found to have invasive breast cancer is always at higher risk of dying prematurely than women without breast cancer. Even thirty years after her diagnosis she is up to sixteen times as likely to die of the disease as a woman in the general population. That is why responsible researchers in this field avoid the word “cure.” Even as they report advances, they must acknowledge the reality: Post-surgical chemotherapy and anti-hormonal therapy do buy time–an important advance. The slowed progress of the disease can give a woman additional years of life and even allow her to die of other, less traumatic, causes.


Cervical cancer is the second most common cancer affecting women after breast cancer, with an estimated 500,000 diagnosed annually worldwide. Cervical cancer accounts for three to five per cent of all deaths among women worldwide. Approximately, 80 per cent of these cervical cancer cases are not diagnosed until they are at an advanced stage. Each year there are about 400,000 new cases of cervical cancer—80% of which occur in women living in developing countries. The vast majority (99.7%) are associated with infection with one or more cancer causing types of human papillomavirus (HPV), which is sexually transmitted. Although women generally are infected with HPV in their teens, 20s or 30s, invasive cancer may not develop for as long as 10 or 20 years after infection. The disease occurs more frequently in younger women.


Mortality rates due to cervical cancer are higher among obese women than among their thinner counterparts. Incidence and mortality rates for cervical cancer can be decreased significantly with early screening for all women beginning at the onset of their sexual activity. Cervical cancer is reported to be the leading cause of death among the Pacific Island women.


Cervical cancer is the eighth most common cancer affecting women in Australia. One in 101 Australian women will develop cervical cancer in their lifetime. The estimated national participation rate in the three-year period 1992-1994 for women aged 20-69 years was 61 per cent, but this has since risen and according to state and territory statistics is now approaching 70%.


Cervical cancer is one of the most preventable and curable of all cancers. It is estimated that up to 90% of the most common type of cervical cancer (squamous cell carcinoma) may be prevented if cell changes are detected and treated early. In recognition of this, in 1991 Australia adopted an ‘organized approach’ to preventing cervical cancer, now known as the National Cervical Screening Program, which recommends and encourages women to have Pap smears every two years, throughout their lives. Each year in Australia more than 1,000 new cases of cervical cancer are diagnosed and over 300 women die from this disease. However with regular Pap smears at two year intervals, and appropriate treatment when abnormalities are detected, most cervical cancer could be prevented.


The National Cervical Screening Program of Australia aims to reduce the incidence and death from cervical cancer through a more organized approach to cervical screening. The Program seeks to integrate all elements of the cervical screening process. The Program includes implementation and monitoring of adherence to a nationally agreed screening policy; establishment of cervical cytology registries in each state and territory; and development and enhancement of other quality management strategies across the screening pathway.


Based on State and Territory statistical reports, the current national screening rate is approaching 70%. However, screening is still low among older women. The risk of cervical cancer increases with age. Although the Pap smear has its limitations, it is the best way currently available for preventing the development of cervical cancer.


A national advertising campaign to increase screening rates began in June 1998. The campaign aims to raise awareness of the need to have two-yearly Pap smears and the benefits of doing so. The campaign encourages all women over 18 to have regular Pap smears. It focuses however on the 35 to 70 year age group as these women participate in screening less frequently than younger women. The national campaign is supported by activities undertaken at a local level by each State and Territory. The National Cervical Screening Program is a joint health initiative of the Commonwealth and State and Territory governments.


In the US, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), administered by the Centers for Disease Control and Prevention (CDC), helps low-income, uninsured, and underserved women gain access to lifesaving screening programs for early detection of breast and cervical cancers. This program, funded at 0.6 million for fiscal year 2003, provides both screening and diagnostic services.


Cervical cancer, which is almost always preventable, continues to be a large public health problem in many developing countries because of limited access to screening and treatment.


Ovarian and uterine cancers are also common cancers of the reproductive system. Accounting for 3% of all cancers in women and figuring more than 165,000 new cases estimated in 2001, ovarian cancer is the sixth most frequent female cancer and the sixth leading cause of death in women worldwide. It has been reported that the incidence of ovarian cancer is on an increase but not as alarming a rate as breast or cervical cancer. For example, Japan has recorded an increase in ovarian cancer incidence from 3.5 per cent in 1955 to 10.5 per cent in 1985.


There is substantial variation in incidence rates of ovarian cancer internationally, from 3/100,000 in central Africa to 13/100,000 in northern Europe. Developing nations have incidence rates that are approximately half those of the most resource-rich countries. Canada and the United States are among the countries with the highest rates of ovarian cancer worldwide, with rates of 12 and 11 per 100,000 respectively. In the US, there are 25,580 new cases for ovarian cancer and is responsible for 13,900 deaths. In Australia, there are 1,201 new cases of ovarian cancer and accounted for 780 deaths in 2000.


Early detection of ovarian carcinoma is difficult, since an ovarian neoplasm usually remains occult until it enlarges or extends enough to produce symptoms. An ovary may grow to considerable size before displaying clinical symptoms. The earliest symptoms are vague lower abdominal discomfort and mild digestive complaints. Swelling of the abdomen due to ovarian enlargement or accumulation of ascetic fluid, pelvic pain, and anemia appear very late in its course. Additional physical signs include the effects of functional tumors like hyperthyroidism.


Endometrial or Uterine cancer is the most common cancer of the female reproductive organs. It is the most deadly of the gynecologic cancers. Endometrial cancer (EC) is the seventh most common malignancy affecting women worldwide, with almost 190,000 cases annually. There is great variation in the incidence rates of EC internationally. The highest risk areas are Central and North America and Polynesia, whereas rates that are 10 times lower occur in western Africa.


In the US, there are 40,320 new cases for uterine cancer in 2004. In Canada, there are 3,800 new cases in women of uterine cancer in 2004. And in Australia, there are 1,654 new cases of uterine cancer in 2000.


            Malignant tumors of the uterus and cervix usually produce vaginal bleeding, but it may occur late in the course of the disease. Cervical cancer in situ is best treated by total abdominal hysterectomy with removal of several cm of vagina. Cancer of the uterine fundus usually requires total abdominal hysterectomy with inclusion of both adnexa and a generous portion of vagina and sacrouterine ligaments. Carcinoma of the cervix frequently occurs in postmenopausal women and is discovered by examination and cytologic smear and confirmed by biopsy.


Other possible reproductive health cancer warning signs are: unusual discharge or bleeding; any unexplained change in toilet habits; a lump in the breast, neck, armpit or anywhere else in the body; and new skin spots, or a spot or mole that has changed in size, color or shape.


            For most women with reproductive health cancers, psychological functioning is indistinguishable from that of physically healthy women 12-24 months after diagnosis if the treatment is complete and the cancer controlled. Although most women remain psychologically strong in the face of cancer diagnosis, several domains of functioning may be affected at various points during diagnosis and treatment.


Tremendous emotional upheaval is common after being diagnosed with cancer. Many cancer patients experience feelings disbelief, shock, fear, and anger. They may also feel overwhelmed by the girth of information about their cancer and their treatment options, by the decisions they are required to make, and by the sudden changes in their lives. It takes time to accept and understand the diagnosis. As overwhelming and painful as a diagnosis of cancer is initially, many cancer survivors say that their struggle against cancer gave them an opportunity to re-evaluate their lives and to find strengths and abilities that they hadn’t known they possessed.


Research shows that lifestyle changes are very common after a reproductive health cancer diagnosis. These changes could be a healthier diet or increased exercise or use of a dietary-supplement. Almost all of the cancer-diagnosed patients overwhelmingly feel that such changes improve their health and well-being. There is somehow hope in cancer-diagnosed patients that a lifestyle change could at least lengthen their lives.


People cope with cancer in their individual ways, but generally after the initial shock of diagnosis and the beginning of treatment, most people are able to resume living as they did prior to cancer.


Cancer no longer equals death. With the advances in medical knowledge about prevention, early detection and treatment, more than half of those diagnosed with cancer today will be effectively treated. Almost nine out of 10 children with cancer are effectively treated and go on to live normal lives. Every day, knowledge about cancer increases and new, more effective treatments are developed, meaning the number of people living with cancer, or in remission, is increasing. An example is the substantial fall in the death rate for breast cancer as a result of early detection and improved treatment.


The type of cancer treatment or combination of treatments that a patient has depends on the type and stage of the cancer. The most common types of cancer treatment are surgery, chemotherapy and radiation therapy. Some cancers can be cured if the tumor is detected and surgically removed before the cancer cells spread. Chemotherapy (anti-cancer drugs) and radiotherapy (radiation treatment) can also cure cancer, by killing cancer cells or stopping them from multiplying. Often these treatments are most effective when used together. The main goal of treatment is to cure the disease, but if cure is not possible, different treatments may be used to control the cancer.


Many people with cancer consider alternative treatments in addition to, or sometimes in place of, the treatment recommended by their doctors. Complementary therapies are supportive methods that are used to complement, or add to, mainstream treatments and these are often recommended by your doctor or another health professional. Complementary methods are not given to cure disease, rather they may help control symptoms and improve well-being. Examples include massage therapy, yoga, meditation, herbal teas and acupuncture. There are many alternative therapies that are promoted as cancer cures. But they are unproven because they have not been scientifically tested, or were tested and found to be ineffective.


            Cancer prevention is defined as the reduction of cancer mortality by reducing the incidence of cancer. This can be accomplished by avoiding a carcinogen or altering its metabolism; pursuing lifestyle or dietary practices that modify cancer-causing factors or genetic predispositions; and/or medical intervention to successfully treat precancerous lesions. Preventive health care is more dynamic than health maintenance because it requires the individual to enhance his or her health status actively, rather than maintain the status quo. The three levels of prevention are primary, secondary, and tertiary ( 2001.)


Primary prevention consists of health promotion activities that are focused on protecting against the occurrence of cancer. It includes teaching patients about healthy lifestyle behaviors. The most consistent finding, over decades of research, is the strong association between cigarette smoking and cancers of many kinds. Not smoking, or giving up, is the single most effective strategy to prevent cancer.


One in eight cancer cases and more than one in five cancer deaths – over 7,700 deaths every year – is caused by cigarette smoking. At least one in three cancer cases are preventable and the number of cancer deaths could be almost halved by the implementation of effective cancer prevention programs. Smoking directly affects a woman’s reproductive organs and her reproductive health in general. Smoking has been identified as a risk factor for cancers of the uterus, cervix, vulva and has been linked to breast cancer. It is estimated that 19% of cervical cancer and 40% of vulvar cancer are attributable to smoking.


Many cancers occur as a direct result of dietary influences, from infectious agents or exposure to radiation, while a few result from inherited faulty or altered genes. An estimated 6000 deaths from cancer per year are due to inadequate intake of vegetables and fruit. A recent Australian study estimates that 10 per cent of cancers could be due to insufficient intake of vegetables and fruit.


Other examples of modifiable cancer risk factors that are open to primary prevention include alcohol consumption, physical inactivity, and being overweight. Based on current evidence, it is now thought that avoiding excessive alcohol consumption, being physically active, and maintaining recommended body weight may all contribute to reductions in risk of certain cancers; however, compared with tobacco exposure, the strength of the effect is modest or small, and therefore the strength of evidence is often weaker. Recent studies in Australia also indicate that regular moderate exercise and maintaining a healthy body weight seem to reduce the risk of some common cancers. Other lifestyle and environmental factors known to affect cancer risk include certain sexual and reproductive practices, the use of exogenous estrogens, exposure to ionizing radiation and ultraviolet radiation, certain occupational and chemical exposures, and infectious agents.


At present national screening programs exist for breast and cervical cancer exist in Australia. The Cancer Council Australia’s National Cancer Prevention Policy advocates for a concerted and comprehensive national approach to the prevention of cancer. It offers clear recommendations on how Australia can enhance its achievements in cancer prevention. The most important preventable cause of cancer is smoking – which directly causes more than 11,000 new cases of cancer each year – that is 12.5% of all new cases of cancer.


The National Cancer Prevention Policy 2004-06 advocates for a concerted and comprehensive national approach to the prevention of cancer. It offers clear recommendations on how Australia can reduce the 85,000 new cases of cancer diagnosed each year. The first section outlines a strategic approach to reducing preventable risk factors relating to: tobacco, ultraviolet radiation, diet, physical activity, obesity/overweight and alcohol. The second section discusses areas where population screening may be an effective approach to reducing the burden of disease. The policy makes specific recommendations for national action by governments and non-government organizations, including programs and strategies to reduce the incidence of cancer. It does not provide information about cancer prevention for individuals.


In the absence of screening programs in poorer countries, primary prevention should take place through health education. By informing women on the early warning signs of reproductive cancers and encouraging them to seek medical examinations and treatment, women would not have to die needlessly.


            Lower cancer mortality data does not necessarily reflect a lower incidence rate, especially for developing countries where there is a lack of screening program and national cancer registries.


Secondary prevention refers to health behaviors that promote early detection, early treatment, and limited disability. For example, genetic testing for high-risk individuals, with enhanced surveillance or prophylactic surgery for those who test positive, is already available for certain types of cancer, including breast cancers. Cervical cytology testing (using the Pap test) leads to the identification and excision of precancerous lesions. Over time, such testing has been followed by a dramatic reduction of cervical cancer incidence and mortality ( 2001).


            Tertiary prevention is directed toward rehabilitation after a disease or condition already exists to minimize disability and help the person to live productively with limitations. Tertiary prevention is used when disability is permanent and irreversible. This type of prevention is aimed at minimizing disease progression effects and disability.


            The presence of cancer in a family produces not only physical but also mental and social problems, which are impossible for the family to cope with alone. There is a demand on the part of the nurse for sympathetic understanding and support in building and maintaining morale of the patient and his or her family.


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 



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