Cervical cancer in palliative care: a case report

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CERVICAL CANCER IN PALLIATIVE CARE: A CASE REPORT

Câncer de colo de útero em cuidados paliativos: um relato de caso

Janaina Rocha dos Santos Aguilar1

Jaqueline Rodrigues Aguiar de Carvalho2 Mayallu Almeida Mendes3 Maria Elisa Martins Moreira4

Abstract: Cancer can be defined as the changes that happen in the cell genetic code, which result in a chronic

disease characterized by the disordered growth of cells. It is seen as a public health problem, especially in

developing countries, and it is expected, over the next few years, an impact of 80in the population of more

than 20 million of new cases estimated by 2025. The reduction of the mortality rate of uterine cancer is

directly related to the early diagnosis of lesions located in the uterine cervix. A world survey conducted in

2012 showed that 60% of the 14 million new estimated cases happened in developing countries. The aim of

the study is to identify the benefits of palliative care for cancer patients. Once the physical and psychological

pains and symptoms can be softened through the actions of the multidisciplinary team, providing comfort

and quality of life. Therefore, palliative care is essential for patients who no longer respond to therapeutic

treatments.

Keywords: Cancer; Palliative care; Patient.

___________

Corresponding author: Janaina Rocha dos Santos Aguilar E-mail: [email protected]

1 Faculdade de Saúde Ibituruna. 2 Centro de Ensino Superior CESESB. 3 Faculdades Unidas do Norte de Minas. 4 Universidade Federal de Minas Gerais.

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REVISTA UNIMONTES CIENTÍFICA

Montes Claros, I Congresso Nacional de Oncologia da Associação Presente - Agosto de 2017.

267 Resumo: O câncer pode ser definido como as alterações que ocorrem no código genético da célula, que

resultam em uma doença crônica caracterizada pelo crescimento desordenado das células. Visto como um

problema de saúde pública, nos países em desenvolvimento principalmente, é esperado para os próximos

anos um impacto na população de 80% dos mais de 20 milhões de casos novos estimados para 2025. A

redução da taxa de mortalidade do câncer de colo de útero está diretamente relacionada com o diagnóstico

precoce de lesões localizadas no colo uterino. Pesquisa mundial realizada em 2012 mostrou que 60% dos

14 milhões de novos casos estimados, ocorreram em países em desenvolvimento. O objetivo do trabalho

é identificar os benefícios dos cuidados paliativos para os pacientes oncológicos. Uma vez que as dores

e os sintomas físicos e psíquicos podem ser amenizados através das ações da equipe multidisciplinar,

proporcionando conforto e qualidade de vida. Portanto os cuidados paliativos e essenciais para pacientes

que não respondem mais a tratamentos terapêuticos.

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INTRODUCTION

Cancer can be defined as the changes that

happen in the cell genetic code, which result in a

chronic disease characterized by the disordered

growth of cells. The genetic inheritance is

responsible for 5 to 10% of the neoplasias and

most are due to environmental factors of chemical,

physical or biological origin, that accumulated

during the entire life of the individual

1

_.

It is seen as a public health problem,

especially in developing countries, and it is

expected, over the next few years, an impact of 80in

the population of more than 20 million of new

cases estimated by 2025. A world survey conducted

in 2012 showed that 60% of the 14 million new

estimated cases happened in developing countries.

The occurrence of cervical cancer occurs

mainly due to infection caused by the human

papilloma virus (HPV), which is a very often

sexually transmitted infection. The cervical cancer

is the most common neoplasia among women,

falling behind only to breast and colorectal cancer

3

_.

It is known that this carcinoma is one of the

most preventable causes of death among women,

but is still very incident among people with low

educational level, low income and difficult access

to health, which present higher death index

4

_.

The most frequent sites of metastases

reported are lungs, bones and liver

5

_{.This cancer}

usually presents loco regional impairment and

its dissemination is related to lymphatic route

directed to the lymph nodes near the pelvis.

According to the World Health Organization,

palliative cares consist of assisting promoted by a

multidisciplinary team, which aims at improving

the quality of life of patients and their families,

faced with a disease that threatens the life, through

the prevention and relief of suffering, the early

identification, assessment and treatment of pain and

other physical, social, psychological and spiritual

symptoms

2.

_{The goal of this work is to identify the}

benefits of palliative cares for the oncological patients.

CASE REPORT

P.G.S., female, 86 years old, born in Coração

de Jesus- MG, retired, Catholic, hypertensive.

Menarche at age 15, first sexual intercourse

absent; she did not perform hormone replacement

therapy, neither cauterization or curettage. A family

history of rectal, intestines cancer and leukemia.

Diagnosis of cervical cancer in 2014,

preventive exam of cervical cancer (PCCU) on

01/11/2014: epithelial cells with atypical epithelial

cells with scarce cytoplasm, increased nuclei and

hyperchromatic necrotic and hemorrhagic bottom

; hemorrhagic smear and with thick areas. Biopsy

on 11/12/2014: Histology compatible poorly

differentiated, infiltrating and ulcerated carcinoma.

She had radiation and chemotherapy/brachytherapy

in the year 2015.Cystostomy in April 2016.

Admitted in palliative care in January

2017. She was referred to the service presenting

bleeding and abdominal discomfort with presence

of bleeding, vegetan tumor at the vaginal introitus.

Before the clinical signals, she was advised to

perform 10 radiotherapy palliative hemostatic

sessions at the vaginal introitus, with improvement

of bleeding symptoms. She evolved with

lymphedema in the pelvic region and the left lower

limb, malaise, PA 120/70mmHg and eupneic, in use

of Tramadol 100mg every 12 hours. She returns to

the care services with pain in the vaginal region

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Montes Claros, I Congresso Nacional de Oncologia da Associação Presente - Agosto de 2017.

269 and abdominal distension, initiated the use of

morphine 30mg every 6 hours.

Patient remained

a week in observation for pain control, nutritional

monitoring and general cares. She is stable.

DISCUSSION

Cervical cancer is the third most common

type in the female population, only falling behind to

breast and colorectal cancer. The estimated new cases

in 2016 were 16,340. Regarding its mortality, it is the

fourth leading cause of death in women with cancer

6

_.

The reduction of the mortality rate of

uterine cancer is directly related to the early

diagnosis of lesions located in the uterine cervix.

This is achieved through screening by Pap Smear,

cervicography, colposcopy and test directed for the

detection of DNA of the Human Papilloma virus

(HPV), bearing in mind that the HPV infection is

known to be related to the onset of this neoplasia

7

_.

The test of Pap smear or colpocytology

, is considered the most effective and

cost-effective for the general population, being the

main strategy of early diagnosis. Currently, it

has high accessibility, reaching rates of coverage

of approximately 85% or more by state with

progressive increase since the establishment of

the National Program for Combating the cervical

cancer in 1998 by the Ministry of Health

10

_.

The Pap smear at regular intervals is

recommended for all women who are between 25

and 64 years old and that has or has had sex life. It

is performed annually and, after two exams without

changes in the intervening period of one year, it shall

be performed every three years, due to the typical

behavior of slow progression of this pathology

8

_.

In 2002, the World Health Organization

defined palliative care as an approach or treatment

that improves the quality of life of patients and

families facing diseases that threaten the continuity

of life, being necessary to assess and monitor

flawlessly not only pain, but all the symptoms

that involve the physical, social, emotional, and

spiritual symptoms. The treatment in palliative

cares must gather the skills of a multiprofessional

team to help the patient to adapt to life changes

imposed by the disease and promote reflection

needed to cope with this condition of threat

to life for patients and family members

9

_.

It was estimated that in approximately

6-10% of patients with advanced cancer bleeding

occurs and at least for some of these patients,

bleeding is the direct cause of death. The bleeding

clinically significant is distressing for the patients

and their families. Thus, the bleeding is likely to

adversely affect the quality of life of the patient.

The effectiveness of the hemostatic radiotherapy

(RT) is usually visible after only a few sessions of

RT and usually explained by an increase of platelets

adhesion to the to vascular endothelium. In the long

term the effect can be explained by the combination

of vascular fibrosis combined with remission of

the tumor. Improving the patient’s well-being

11

_.

When detected in its early stages, the cure

rates of cervical cancer are close to 100%. However,

in the case presented, the patient received a delayed

diagnosis, which corroborates to the ineffective

treatment directed at total remission of the disease.

This demonstrates, then, the elementary need to

establish interventions aimed at the screening in

the target population to offer greater chances of

cure. It is possible to infer about the importance of

palliative care in the improvement of quality of life

and the stability of the patient presented at the case.

FINAL CONSIDERATIONS

In the field of women’s health, the Pap smear

is an important tool used by the Ministry of Health

for the screening of cervical cancer, a strategy used

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v. 24, n. 3, p. 282-285, 2016. Disponível em: <

http://www.scielo.br/scielo.php?pid=S1414-4 6 2 X 2 0 1 6 0 0 0 3 0 0 2 8 2 & s c r i p t = s c i _

abstract>

acesso

em:

23 Jul.

2017.

5. BENOULAID M. et al. Skin metastases of

cervical cancer: two case reports and review of

the literature. Journal of Medical Case Reports.

v. 10, n. 265, p.3-4, 2016. Disponível em: <

https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC5035488/> acesso em: 19 Jul. 2017.

6. MELO, M. C. S. C. et al. O enfermeiro

na prevenção do câncer de colo de útero: O

cotidiano da atenção básica. Revista Brasileira

de Cancerologia. V. 58, n. 3, p. 389-398,

2012. Disponível em: <

http://www1.inca.gov.

br/rbc/n_58/v03/pdf/08_artigo_enfermeiro_

prevencao_cancer_colo_utero_cotidiano_

atencao_primaria.pdf> acesso em: 24 Jul. 2017.

7. PINHO, A. A; FRANCA. J. I. Prevenção do

câncer de colo do útero: um modelo teórico

para analisar o acesso e a utilização do teste

de Papanicolaou. Revista Brasileira de Saúde

Materno Infantil, v. 3, n. 1, p. 95-112, 2003.

Disponível em: <

http://www.scielo.br/scielo.

php?pid=S151938292003000100012&script=sci_

abstract&tlng=pt> acesso em: 19 Jul. 2017.

8. BRASIL. Ministério da Saúde. Diretrizes

para o rastreamento de Câncer do Colo do

Útero. Instituto Nacional do Câncer. 2011.

Disponível em: <

http://bvsms.saude.gov.br/

bvs/publicacoes/inca/rastreamento_cancer_

colo_utero.pdf> acesso em: 23 Jul 2017.

9. RODRIGUES, L. A; LIGEIRO, C; SILVA, M.

Cuidados paliativos, diagnósticos e terminalidade:

indicação e início do processo de paliação. Revista

Cuidarte Enfermagem, v. 9, n. 1, p. 26-35, 2015.

Disponível em: <

http://fundacaopadrealbino.org.

br/facfipa/ner/pdf/Revistacuidarteenfermagem%20

v. % 2 0 9 % 2 0 n . 1 % 2 0 % 2 0 j a n . % 2 0 j u n % 2 0

2015.pdf> acesso em: 24 Jul. 2017.

10. BRASIL. Ministério da Saúde. Instituto Nacional

de Câncer José Alencar Gomes da Silva.Rio de Janeiro:

INCA, 2011. Disponível em: <http://www.inca.

gov.br/estimativa/2016/> acesso em: 18/06/2017

initially by primary care. In the case presented it

was the first tool used for the diagnosis of cancer.

The palliative care can be described as

the total and active care to patients who do not

respond anymore to therapy treatments, having

as the supreme purpose control of pain and other

symptoms associated, at the same time that the social

and spiritual problems are treated, and therefore it

is possible to ensure the patients and families the

best quality of life possible. It is necessary to make

understand that palliative care do not anticipate

or defer the end of life, but it allows to show that

death is just one more natural step of life. The

importance of palliative cares is ratified by the

effective control of symptoms and improvement

of the comfort of the patient in question.

REFERENCES

1. MUNHOZ, M. P. et al. Efeito do exercício

físico e da nutrição na prevenção do câncer.

Revista Odontológica de Araçatuba

, v. 37,

n. 2, p. 09-16, 2016. Disponível em: <

http://

a p c d a r a c a t u b a . c o m . b r / r e v i s t a / 2 0 1 6 / 0 8 /

trabalho5.pdf> acesso em: 18 Jul. 2017.

2. BRASIL. Ministério da Saúde. Instituto Nacional

de Câncer José Alencar Gomes da Silva. 2016:

incidência de câncer no Brasil. Rio de Janeiro:

INCA, 2015. Disponível em: <

http://www.inca.

gov.br/estimativa/2016/> acesso em: 22 Jul. 2017.

3. OKAMOTO, C. T. et al. Perfil do Conhecimento

de Estudantes de uma Universidade Particular de

Curitiba em relação ao HPV e Sua Prevenção.

Revista

brasileira de educação medica, v. 40, n. 4, p. 611-620,

2016. Disponível em: <

http://www.scielo.br/scielo.

php?pid=S010055022016000400611&script=sci_

abstract&tlng=pt> acesso em: 18 Jul. 2017.

4. MADEIRO, A. et al . Tendências da mortalidade

por câncer do colo do útero no Piauí,

2000-2011.

Caderno de saúde coletiva, Rio de Janeiro,

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Cervical cancer in palliative care: a case report

AGUILAR, J. R. S; CARAVALHO, J. R. A.; MENDES, M. A.; MOREIRA, M. E. M. ISSN 2236-5257