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| CONTINUING EDUCATION SERIES NO: 36 |
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| Year : 2019 | Volume
: 20
| Issue : 1 | Page : 46-56 |
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Gynaecological cancers
Diana David, Ebenezer E Benjamin
College of Nursing, CMC, Vellore, Tamil Nadu, India
| Date of Web Publication | 09-Oct-2019 |
Correspondence Address:
Prof. Diana David
College of Nursing, CMC, Vellore, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJCN.IJCN_3_19
Gynaecological cancers are cancers of the female reproductive system, mainly including uterine/endometrial cancer, ovarian cancer, cervical cancer, vaginal cancer, vulvar cancer, fallopian tube cancer and trophoblastic tumour. Gynaecological cancers are often detected as a result of general screening procedures. Very few women are compliant with routine examinations; therefore, it is imperative that women are aware of some indicators of these cancers and get help at an early stage if needed. Some of these indicators are unusual bleeding, pain or pressure in the pelvis; unusual vaginal discharge; change in the toilet habits or itching, burning or soreness in the perineum. Treatment depends on the type of cancer, stage, location and general health of the woman. The decision for a single treatment or a combination becomes very challenging, especially when the woman is young and cancer is advanced. Nurses need to be knowledgeable about gynaecological cancers and proficient in caring for women with gynaecological cancers. Keywords: Gynaecological cancers, nurses, women
How to cite this article:
David D, Benjamin EE. Gynaecological cancers. Indian J Cont Nsg Edn 2019;20:46-56 |
| Introduction | |  |
Gynaecological cancers are considered to be among the most common cancers in women and hence an important public health issue. The lack of cancer awareness, variable pathology and dearth of proper screening facilities in developing countries such as India causes most women to report cancer-related manifestations at advanced stages, thereby adversely affecting the prognosis and clinical outcomes.[1]
This article elaborates on the five gynaecological cancers, namely vulval, vaginal, cervical, ovarian and endometrial. Ovarian and cervical cancers are identified to be the most common gynaecological cancers affecting women worldwide and in India. There is an alarming rise in cervical cancer second only to breast cancer. A survey shows that every year in India, 122,844 women are diagnosed with cervical cancer and 67,477 die from this disease.[2]
These five cancers may present in variable forms clinically, and symptoms of cancer in women manifest differently at different stages of illness. Consequently, these conditions are often not identified as early as they should be as awareness levels of these cancers are relatively low. Open communication is a very important step towards greater awareness of symptoms and ultimately early diagnosis for all gynaecological cancers.
| Vulval Cancer | | |
'Vulvar and vaginal squamous cell carcinomas are rare malignancies with a world-standardised annual incidence of around 1–3/100,000 women. The disease occurs mainly among women in their 60s or 70s'.[3]
There are two types of squamous cell carcinomas with different risk factors:
- Type 1 – Warty basaloid type in the younger age group mainly caused by human papillomavirus (HPV) infection, pre-existing vulval intraepithelial neoplasia (pre-cancerous growth), cervical intraepithelial neoplasia (pre-cancerous growth), sexually transmitted diseases, smoking and immunosuppression
- Type 2 – Keratinising type in the older age group due to gene mutation and non-neoplastic diseases of the vulva.
Aetiology
This cancer usually occurs in post-menopausal women about 60 years of age. HPV infections are identified as an essential although not sufficient factor in the pathogenesis of vulval and vagina carcinomas.[4] Other factors include obesity, hypertension, diabetes, nulliparity, poor hygiene, cervical malignancies and chronic vulval dystrophy. The risk factors of vulvar cancer are outlined in [Table 1].[5]
Symptoms
Women with vulvar cancer are mostly asymptomatic initially. Symptoms in the later period include long-standing pruritus, bleeding, discharge, pain, non-healing ulcer, warty growth, inguinal mass, dysuria and discharge. Lesions can be unilateral/bilateral, fleshy warty growth, ulcer, red/white colour and tender/painless. The most generally depicted side effect of vulvar malignancy is a long history of pruritus. The most evident indication of vulvar malignant growth is a vulvar irregularity or mass, which may present ulcerated, leucoplakic, plump or warty.[6] The stages of vulvar cancer are depicted in [Table 2].[5]
Clinical evaluation
A complete history for women with vulval cancer including signs and symptoms, history of malignancy, cigarette smoking and history of multiple sexual partners needs to be considered. Physical examination involves assessing the size, location and type of the lesion and extension to the perineum/perianal region. Investigations include biopsy, Pap smear and colposcopy to assess the cervix including cystourethroscopy and proctoscopy. Scan/computed tomography (CT)/magnetic resonance imaging (MRI) is used for pelvic nodes and deep infiltration of the lesions and positive emission tomography (PET) scan for nodal metastasis and haematologic spread. The diagnosis can be confirmed on wedge biopsy.
| Management | | |
The different factors affecting treatment are age, conjunction of comorbidities and execution status of the patient.[7] The surgical approaches to treat cancer of the vulva include simple vulvectomy that involves removal of labia majora, labia minora, glans clitoris and sometimes perineal area, and radical vulvectomy involves excision of tissues from the anus to a few centimetres below the symphysis pubis, labia majora, labia minora, clitoris and bilateral dissection of the groin lymph nodes. Radiation involves 3000 rad in a week, and chemotherapy includes an infusion of 5 Flurouracil and mitomycin C.
Complications
Squamous cell carcinoma of the vulva apparently recurs in 30%–50% of patients in the initial 2 years. The majority of these are local recurrences; however, one-third of recurrences are in the groin and are associated with a poor prognosis.[8]
Immediate post-operative complications include wound infection, haemorrhage and thromboembolism, and late complications include scaring, disfigurement, vulval stenosis, dyspareunia, sexual dysfunction, lymphoma, lymphedema, genital prolapse and stress urinary incontinence.
| Vaginal Cancer | | |
'Primary vaginal carcinoma is rare and comprises only 1%–2% of all gynaecologic malignancies'.[9] The average age of diagnosis is 60–65 years. Primarily being the squamous cell type, the others are adenocarcinomas, melanomas and sarcomas.
Embryonal rhabdomyosarcoma (RMS), a common type of vaginal cancer, is seen in early childhood period. RMS is a malignant tumour which arises from embryonic muscle cells. It is the most common soft-tissue sarcoma in childhood and young adulthood and accounts for 4%–6% of all malignancies in this age group.[10]
Risk factors
Risk factors for vaginal cancer include HIV infection, HPV infection, repeated pregnancies, previous radiation therapy, smoking, diethylstilbestrol exposure, cancer of another genital organ, lower socioeconomic status and lichen sclerosus. FIGO staging[11] for vaginal cancer is outlined in [Table 3].
Symptoms and signs of vaginal cancer
Cancer is found through routine gynaecological examination. Common symptoms include abnormal vaginal bleeding – post-coital, intermenstrual, pre-pubertal or post-menopausal. Other symptoms include difficult/painful urination, dyspareunia and pain in the pelvic area. Advanced tumours affecting the rectum/bladder or extending to the pelvic wall cause pain/leg oedema.
Clinical evaluation
If a gross lesion could be identified in a pelvic examination, a punch biopsy of the lesion can be performed to diagnose vaginal cancer. Biopsy may be obtained with a Tischler biopsy forceps. If a gross lesion is not seen or identified, biopsy may be done during vaginoscopy. Bimanual examination helps in determining the tumour size, and rectovaginal examination is especially important for posterior wall lesions.[12] CT scanning can delineate the size and extent of many tumours. However, if the extent of cancer expansion is unclear, MRI is the most useful radiologic tool available to visualise the vagina. Fluorodeoxyglucose-PET (FDG-PET) can also be selected to evaluate lymph node involvement and distant metastases. In one study, FDG-PET was more sensitive than CT for detection of abnormal lymph nodes.[13]
Management
The treatment is individualised based on factors such as tumour type, stage, location and size. Surgery and radiotherapy are considered as treatment options for Stage I disease. Surgery is the most preferred form of treatment if negative surgical margins can be achieved. Surgery includes radical vaginectomy and pelvic lymphadenectomy for most tumours located in the upper third of the vaginal vault. Most early-stage vaginal cancers are treated by surgery such as radical hysterectomy, lymphadenectomy and vaginectomy.[12] Radiotherapy and chemotherapy can be considered for Stage II to IV and pelvic exenteration where bladder and rectum are involved in Stage IV with fistulae. Stock et al.[14] identified a significant survival advantage at 5 years in those with Stage II disease treated with surgery compared with those treated with radiation (62% versus 53%). An audit report of the National Cancer Data Base identified that the 5-year survival rate for women with Stage II disease treated with surgery alone was 70%, with radiotherapy alone was 57% and with a combination of surgery and radiotherapy was 58%.[15]
| Cervical Cancer | | |
'Cervical cancer is the second most commonly diagnosed cancer and the third leading cause of cancer death among females in less developed countries. There were an estimated 527,600 new cervical cancer cases and 265,700 deaths worldwide in 2012'.[16] Squamous cell carcinomas are common among women in their 20s. Adenocarcinoma of the endocervix is comparatively rare and is common in young women with 25% of patients being <35 years old.[17]
The incidence of invasive cervical cancer is 10/100,000. The majority of the types of cervical cancer are squamous cell carcinomas, however adenocarcinomas, adenosquamous and undifferentiated carcinomas and other rare histological types may also occur.[18] 'The World Health Organization recognises three categories of epithelial tumours of the cervix: squamous, glandular (adenocarcinoma) and other epithelial tumours including adenosquamous carcinoma, neuroendocrine tumours and undifferentiated carcinoma'.[19]
Staging carcinoma of the cervix uteri
- Stage I – The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded)
- IA – Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion ≤5 mm and largest extension ≥7 mm
- IA1 – Measured stromal invasion of ≤3 mm in depth and extension of ≤7 mm
- IA2 – Measured stromal invasion of >3 mm and not >5 mm with an extension of not >7 mm IB. Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than Stage IA * IB1. Clinically visible lesion ≤4 cm in greatest dimension
- IB2 – Clinically visible lesion >4 cm in greatest dimension.
- Stage II – Cervical carcinoma invades beyond the uterus but not to the pelvic wall or to the lower third of the vagina
- IIA – Without parametrial invasion
- IIA1 – Clinically visible lesion ≤4 cm in greatest dimension
- IIA2 – Clinically visible lesion >4 cm in greatest dimension
- IIB –With obvious parametrial invasion.
- Stage III – The tumour extends to the pelvic wall and/or involves the lower third of the vagina and/or causes hydronephrosis or non-functioning kidney**
- IIIA – Tumour involves the lower third of the vagina, with no extension to the pelvic wall
- IIIB – Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney.
- Stage IV – The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum.
- IVA – Spread of the growth to adjacent organs
- IVB – Spread to distant organs.[18]
Aetiology and risk factors
The aetiology of cervical cancer includes early-onset sexual activity, multiple sexual partners, history of HPV infection, sexually transmitted infections such as chlamydia, genital herpes, HIV infection, immunosuppressive agents, early age at first pregnancy, multiparity, consumption of oral contraceptive pills, genetic factors, multiple pregnancies, low consumption of fruits and vegetables in the diet, lower socioeconomic status, poor hygiene and obesity.
Signs and symptoms of cervical cancer
In early cervical cancer, there may be no obvious clinical symptoms as the disease progresses. Symptoms often do not appear until the cancer invades nearby tissues. When this happens, women may experience symptoms which are listed below.
- Abnormal uterine bleeding – Intermenstrual bleeding, post-menopausal bleeding, post-coital bleeding, continuous bleeding and uncontrolled profuse bleeding and vaginal discharge which is foul smelling or blood stained
- Pain – pelvic pain, low back pain and pain radiating down to the posterior thighs
- Pedal oedema, haematuria, urinary incontinence and faecal incontinence.[5]
Other symptoms include vaginal discharge, dyspareunia, exophytic growth like cauliflower shaped, fungating, bleeding on touch, friable and indurated/barrel shaped, hard endophytic growth/ulcerative lesion, vaginal extension of the tumour, enlarged uterus and tender in case of pyometra.[5]
Clinical evaluation
A physical examination which includes a pelvic examination of the vulva, vagina and cervix to feel the reproductive organs including the cervix, uterus and ovaries to check for abnormalities is performed. Diagnostic tests done are individualised for clients. These tests include chest X-ray, CT, MRI, PET and FDG-PET. When tumours are large invasive, procedures such as cystoscopy, proctoscopy and laparoscopy are done. The Pap test is most widely used for cervical cancer screening method. HPV testing, which is an adjunct to Pap testing, is used to look for the presence of DNA or RNA from cervical cells.[5]
Management
Factors such as general health, individual preferences and the desire to have children influence treatment. The procedures which are commonly performed include total hysterectomy, radical hysterectomy and pelvic exenteration.[20] Wertheim's hysterectomy is removal of the entire uterus, both adnexa, pelvic lymph nodes, one-third of the parametrium and one-third of the vagina. Laser surgery is employed when cancer is limited to the cervical epithelium. Cryosurgery which involves the use of a probe to freeze tissue causing necrosis and sloughing is utilised for non-invasive lesions. Conisation is a procedure in which pelvic exenteration or removal of pelvic contents of the bowel, vagina and bladder is done. Radiation therapy is given to destroy the tumour, reduce its size, decrease pain or relieve obstruction, especially when resources for surgery are limited. The chemotherapy drugs that are used include cisplatin, carboplatin, paclitaxel, topotecan and gemcitabine. The chemotherapeutic agent most commonly used as radiosensitiser is cisplatin.[21]
| Ovarian Cancer | | |
Ovarian cancer (OC) is the most lethal female reproductive tract malignancy with >190,000 new cases diagnosed each year worldwide. OC is the second most common of all genital cancers and accounts for 10%–15% of all gynaecological cancers in the developing countries including India. It commonly occurs in post-menopausal women and generally above the age of 50 years. Over the past two decades, there has been an increase in the incidence and survival rates among women with OC. Most cases are diagnosed late because of unavailability of effective screening methods. OC is the third most diagnosed gynaecologic cancer and the first leading cause of death from all gynaecological malignancies. OC presents with the highest mortality rate, largely due to its advanced stage at the time of diagnosis.[18]
OCs are broadly classified into three groups:
- Epithelial cancers (70%)
- Germ cell tumours (5%–10%)
- Sex cord-stromal tumours (15%–20%).
Risk factors
The well-known risk factors include older age group; nulliparity; infertility; early menarche; late menopause; endometriosis; polycystic ovarian syndrome; breast cancer antigen gene mutation; diet rich in animal fat; perineal exposure to talc; obesity; family history of breast, uterus, colon or rectal cancer; personal history of breast, uterus, colon or rectal cancer and menopausal hormone therapy. A multiparity woman has a lower risk of OC compared to a nulliparous woman.
Symptoms
In the initial period, OC is asymptomatic. Symptoms in the later period include abdominal pain, abdominal distension/bloating, difficulty in eating/feeling full weight loss, dyspnoea, nausea, abdominal mass, urinary frequency, irregular menstruation/post-menopausal bleeding, vaginal discharge and constipation
Clinical evaluation
A complete physical examination is the first step in the diagnosis of OC, including an abdominal examination, bimanual examination and rectovaginal examination. Findings such as a fixed pelvic mass, nodularity of the cul-de-sac, ascites or omental nodularity may help elucidate the extent of disease and prepare for treatment planning. Further diagnostic workup will be established to analyse the extent of disease and exclude other causes of an adnexal mass, carcinomatosis or ascites.[22]
Management
The treatment of early-stage OC involves surgical resection followed by chemotherapy. Promising advances in understanding the history of OC, along with surgical and chemotherapeutic strategies, have significantly improved the short-term course of OC. Despite these improvements, most patients relapse after the first treatment and succumb to disease progression.[23] Chemotherapy is the use of certain medications to destroy cancer cells. The treatment usually involves 3–6 chemotherapy sessions or cycles. These will be given 3–4 weeks apart, to allow the body time to recover.
| Endometrial Carcinoma | | |
Uterine cancer is the fifth most common malignancy in UK women with an incidence of 20/1,000,001. The majority are adenocarcinomas arising from the endometrium. Most women (94%) are over the age of 50 years. Early-stage presentation is the norm, reflected by an overall 5-year survival of 75%. However, an improving survival rate has been offset by a rise in incidence of 24% (1993–2003). Other uterine tumours such as carcinosarcomas (malignant mixed Mullerian tumours) and malignant myometrial tumours (leiomyosarcoma) are uncommon or rare.[18] High occurrences are noted in post-menopausal woman around 60–70 years of age and about 75% of cases around 50 years of age; the cancer has a lower mortality rate compared to other gynaecological cancers due to early presentation but carrying a risk of cardiovascular disease. Endometrial cancer is generally associated with a favourable prognosis. A key factor leading to this good prognosis is that most cases are diagnosed at an early stage. The most important prognostic factors at diagnosis are stage, grade, depth of invasive disease, Lymphovascular Space Invasion (LVSI) and histological subtype. Endometrial tumours have a 5-year survival of 83% compared with 62% for clear cell and 53% for papillary carcinomas. LVSI is present in 25% of cases. Five-year overall survival is 64% and 88% with or without LVSI, respectively.[24] The stages of endometrial cancer is outlined in [Table 4][5].
Types
Type 1 – Grade 1 or 2 endometrioid: This constitutes 80% and occurs in younger, nulliparous, obese and oestrogen-dependent women. It is contraceptive and smoking protective. Prognosis is favourable.
Type 2 – Grade 3 or non-endometrioid: This constitutes 20% and occurs in older, multiparous and non-obese women. It is non-oestrogen dependent and not smoking protective. Prognosis is poor.
Risk factors
The risk factors for endometrial cancer include age >50 years, obesity, unopposed oestrogen use, tamoxifen use, infertility, early menarche, early menopause, diabetes and heredity.[5]
Symptoms
The most common symptoms in women with endometrial cancer include abnormal vaginal bleeding which is an early symptom associated with endometrial cancer. In around 10% of women, post-menopausal bleeding is also a symptom of endometrial cancer. Less frequently noted other symptoms include serosanguinous vaginal discharge; haematometra; pyometra; irregular or heavy bleeding; abdominal distention and lumbosacral, hypogastric and pelvic pain.[25]
Clinical evaluation
A history of women with post-menopausal bleeding should include an in-depth description of presenting symptoms such as onset of symptoms, duration, amount, intensity, colour, consistency and cramping. Other important information to be elicited includes assessment for risk factors, which includes hormone usage, weight changes, tamoxifen usage and dietary habits. Family history includes history of breast cancer and medical conditions such as diabetes, hypertension and obesity.[26]
Diagnosis
Physical examination includes nodal surveillance particularly supraclavicular and inguinal nodes, lungs, abdomen, abdominal examination for uterine enlargement, ascites and hepatomegaly, per speculum examination for bleeding and Pap smear, pelvic examination for uterine enlargement, tenderness and adnexal mass.
Management
Management includes surgical excision such as hysterectomy, oophorectomy and lymphadenectomy. External radiation and brachytherapy may also be given. Hormone therapy may be considered in advanced endometrial cancer, spread beyond the uterus.
| Nursing Management | | |
According to Holt et al.,[27] nursing goals for women with gynaecological cancer include six categories: physical, emotional, social, existential, cognitive and sexual functioning. Nursing care starts even before the diagnosis of a cancer is made. Nurses' role in screening and early identification of gynaecological cancer is vital, especially in the community or in the outpatient setting. Nurses should be knowledgeable and be able to carry out appropriate physical examination and take smears and tests. The development of nursing partnerships helps women with gynaecological cancer to gain essential knowledge and information and in turn fosters decision-making. Effective communication is the essence of good relationships between health professionals and patients. During hospitalisation, their concerns related to loss of body organs, body image, pain, privacy and relationship issues should be addressed through mutual goal setting and planning of care. Teaching and support during chemo- and radiation therapy and the management of side effects should also be an essential part of nursing care. A holistic approach to patients' psychological, social and sexual rehabilitation following treatment for gynaecological cancer is needed, and this can be provided by a collaborative team of professionals in which a nurse plays a lead role[28] As Miller[29] suggests, there are five major roles that nurses play, namely clinical expert, researcher, consultant, teacher and agent for change. Nurses providing care to women's gynaecological cancer need to be information givers, clinical experts in providing holistic care, counsellors to meet the psychological needs and coordinators in providing holistic healthcare. The involvement of the nurses in providing relevant information at the patient's level of understanding as well as coordinating their cancer care is paramount in order to empower women with gynaecological cancers to psychologically, socially, spiritually and sexually survive their cancer.
| Conclusion | | |
Increasing incidence of gynaecological cancers has indicated the need for early identification and treatment to promote well-being in women of all ages. Different parts of the female reproductive system may develop different types of cancers. Gynaecological cancer screening helps in early identification and therefore improves the overall outcomes. Being diagnosed with cancer and the treatment that follows can be a very difficult experience to cope with for patients and their families. The nurses' role includes screening, providing information about diagnosis, treatment and management, psychological support, being a clinical expert and a coordinator in the healthcare team.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| Questions-Gyanecological cancers | | |
- The most serious gynecological cancer is
- Cervical cancer
- Uterine sarcomas
- Ovarian cancer
- Endometrial cancer
- Which factor places a woman at risk for ovarian cancer?
- Obesity
- Nulliparity
- Lack of exercise
- Diabetes
- Endometrial cancer commonly occurs among
- Adolescents
- Women of the reproductive age groups
- Premenopausal women
- Postmenopausal women
- Mrs. A, a 35 year old client is admitted with advanced ovarian cancer, which symptom would the nurse recognize as typical of the disease during the admission?
- Diarrhea
- Hypermenorhea
- Abdominal bleeding
- Abdominal distention
- The nurse is collecting history from a 40 year old lady who is attending the gyanecology clinic. Which of the following history findings is a risk factor for cervical cancer?
- Onset of sporadic sexual activity at 17yrs of age
- Spontaneous abortion at 19yrs of age
- Pregnancy complicated with eclampsia at 30yrs
- HPV infection at 32yrs of age
- While preparing discharge for a client, 4 days after an abdominal hysterectomy, the nurse should instruct the client to avoid which of the following activity until recovery is complete?
- Swimming in a pool 6 weeks after surgery
- Walking 30 minutes at least once a day
- Resuming sexual activity after 6 weeks
- Lifting objects weighing more than 2 kg after 2 weeks
- HPV vaccine is given to prevent
- Endometrial carcinoma
- Ovarian cancer
- Cervical cancer
- Vaginal cancer
- Which is the most common type of cervical cancer?
- Adenocarcinoma
- Squamous cell carcinoma
- Adenosquamous carcinoma
- Undifferentiated carcinomas
- The most common chemotherapeutic agent which is used to treat cervical cancer is
- Cisplatin
- Carboplatin
- Paclitaxel
- Topotecan
- The treatment option in advanced endometrial cancer is
- Chemotherapy
- Radiotherapy
- Hormone therapy
- Surgery
- The most common presenting feature in women with vulval cancer is
- Bleeding
- Dysuria
- Pruritis
- Pedal edema
- A women presents with the features of vulval cancer. What diagnostic test the treating physician would order to confirm the diagnosis?
- Wedge biopsy
- Pap smear
- Magnetic Resonance Imaging (MRI)
- Positron Emission Tomography (PET) scan
- A 5 year old child presents with bleeding per vagina and vaginal mass. The probable diagnosis would be
- Vulval cancer
- Endometrial cancer
- Squamous cell carcinoma
- Embryonal Rhabdomyosarcoma
- Prolonged exposure to synthetic form of estrogen leads to
- Vulval cancer
- Vaginal cancer
- Endometriosis
- Ectopic pregnancy
- According to FIGO, stage III in vaginal cancer refers to
- Tumor involving subvaginal tissue
- Tumor extending to pelvic wall
- Tumor invading bladder
- Tumor spreading to distant organ
- Pelvic exenteration involves removal of
- Uterus, cervix, vagina, bladder, rectum
- Vagina, cervix, bladder, rectum, ureters
- Uterus, vagina, cervix, bladder, processus vaginalis
- Uterus, vagina, cervix, rectum, omentum
- Mrs. S is diagnosed to have endometrial type-1 tumor. The nurse must understand that
- It is common in multiparous women
- The longevity of life is better
- It is more common in older women
- It is a nonestrogen dependent tumor
- While assessing Mrs. J with endometrial tumor, the nurse identifies that the inguinal nodes are palpable. Nurse will stage the cancer as
- III a
- III b
- III c
- IV
- Which of the following condition highly predisposes a woman to endometrial tumors
- Early menarche, late menopause
- Early menarche, early menopause
- Late menarche, late menopause
- Late menarche, early menopause
- Women who has been treated with hormonal therapy for breast cancer is most likely to have the following cancer due to the side effect
- Vulval
- Vaginal
- Cervical
- Endometrial
CE Test No:36
Gynecological Cancers
Select the best answer and shade the circle against the suitable alphabet in the answer form provided.
| Answer Form | | |
Evaluation: Listed below are statements about the CNE on ‘Gynecological Cancers’. Please circle the number that best indicates your response.
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Stated Objectives were met 1 2 3 4
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[Table 1], [Table 2], [Table 3], [Table 4]
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