Case study - Endometrial cancer: Nursing

Nurse Taylor works in an oncology office and is caring for Sarah, a 60 year old postmenopausal woman. Sarah recently noticed uterine bleeding and went to her obstetrician gynecologist or OBGYN who conducted a pelvic exam and transvaginal ultrasound that showed a pelvic mass and an abnormally thick endometrium.

Her OBGYN performed a biopsy on the endometrium, which identified type one endometrial carcinoma. Sarah was then referred to the oncology clinic for further evaluation and next steps.

As nurse Taylor reviews Sarah's history, Taylor notes that Sarah has a body mass index, or BMI of 31.2. She also has a history of polycystic ovarian syndrome, or PCOS and has never been pregnant, and experienced menopause at age 57, which is considered late-onset menopause.

While awaiting discussion about further treatment with the oncologist, nurse Taylor begins planning and implementing care for Sarah.

First, nurse Taylor considers the pathology of endometrial cancer and connects it with Sarah's medical history. Endometrial cancer typically develops in post-menopausal individuals over the age of 50, when malignant cells form in the endometrium or uterine lining.

Postmenopausal uterine bleeding is abnormal, and is often the first symptom of endometrial cancer. Nurse Taylor considers the two types of endometrial cancer, type 1 and type 2.

Type 1 is driven by prolonged exposure to estrogen, which initiates endometrial growth without the antagonistic effects of progesterone, which inhibits the proliferation of endometrial cells.

This hormonal imbalance can cause endometrial hyperplasia, or an increase in the number of endometrial cells that can eventually lead to malignant changes.

On the other hand, type 2 is less common. It isn't estrogen-dependent, doesn't involve hyperplasia, and is more aggressive.

Type 2 also tends to develop later in life and in individuals with lower body weight. Nurse Taylor recognizes several factors that could have contributed to Sarah developing type one endometrial cancer.

Sarah experienced prolonged exposure to elevated estrogen levels due to a higher BMI since adipose tissue produces estrogen.

Her PCOS also played a role, because during anovulatory cycles, when ovulation doesn't occur, progesterone doesn't balance estrogen levels.

Sarah also didn't experience the protective effects of pregnancy and breastfeeding, a period of extended progesterone dominance.

Lastly, her lifetime exposure to estrogen was increased since she experienced menopause later than average. While many of Sarah's risk factors relate to increased estrogen exposure, nurse Taylor also recognizes there are genetic risk factors for endometrial cancer, including Lynch syndrome, Cowden syndrome, and a family history of certain cancers.

Treatment for Sarah will depend on the staging of the cancer, which determines the size of the tumor and how far and deep it has spread, as well as grading, which looks at how abnormal the cancer cells are.

Imaging studies can be used to guide treatment planning. Treatment is most often surgical, which involves a hysterectomy to remove the uterus and sometimes the ovaries, fallopian tubes, and nearby lymph nodes.

For more complex cases, radiation or chemotherapy may be added. The good news is that the prognosis is favorable for patients when the cancer is diagnosed early.

Next, nurse Taylor helps Sarah into the exam room and begins to gather more information. Taylor obtains Sarah's vital signs, which are temperature 98.4 °F or 36.9 °C, BP 124/68 millimeters of mercury, heart rate, 82 BPM, respirations, 18 breaths per minute, and oxygen saturation 97% on room air.

Taylor notices that Sarah looks pale and checks the electronic health record, which reveals a hemoglobin of 11.2 g per deciliter, and a hematocrit of 29%.

Findings consistent with mild anemia. How are you feeling, Sarah?

Exhausted and worried, I'm still having bleeding too. I'm sorry you're going through this.

It makes sense that you feel this way. Nurse Taylor pieces the assessment findings together and understands that Sarah's uterine bleeding can contribute to her anemia, which is manifested by pallor and fatigue.

Taylor recognizes that these symptoms, along with her new diagnosis of cancer, are causing Sarah significant anxiety. Using the information they've gathered, nurse Taylor notes Sarah's priority problems as fatigue and anxiety related to her new cancer diagnosis.

With these priorities in mind, nurse Taylor notes individualized, measurable goals aimed at improving activity tolerance and decreasing anxiety by her follow-up appointment.

Nurse Taylor reviews the healthcare provider's orders and notes that Sarah was prescribed an oral iron supplement. Your healthcare provider prescribed oral iron supplements, which should help your energy improve.

Bleeding can drop your iron levels and make you feel tired. I'll try those.

I'm just concerned about what comes next. A new cancer diagnosis can be scary, especially when you're not feeling great.

We're here to walk you through this. Sarah seems to be encouraged and begins to relax.

Nurse Taylor will continue to monitor and re-evaluate Sarah's fatigue and anxiety at her next office visit. Next, nurse Taylor reinforces education provided by the healthcare team about endometrial cancer, and reviews how it can cause abnormal uterine bleeding.

Taylor reminds Sarah to notify the healthcare team if she feels increasingly fatigued or develops new symptoms, such as worsening pain, fever, or unusual discharge.

Sarah is advised to seek immediate care if she is soaking a pad within one hour, passing large clots, or feeling dizzy or faint.

Nurse Taylor also explains that the healthcare provider ordered imaging, which will help guide the next steps in Sarah's treatment, and reviews the general treatment approaches that may be considered, such as surgery, radiation, or chemotherapy.

Nurse Taylor also reminds Sarah to attend her follow-up office, lab, and imaging appointments. Finally, nurse Taylor reviews community resources and support groups available for individuals with a new cancer diagnosis, and offers to connect Sarah with a therapist for additional support.

All right, it's a quick recap. Nurse Taylor observed clinical manifestations related to Sarah's endometrial cancer diagnosis, including abnormal uterine bleeding, fatigue, and anxiety.

Taylor connected these findings to a history of prolonged estrogen exposure, identified priority problems, implemented care, and monitored Sarah's response.

Taylor also provided educational materials on endometrial cancer, anxiety reduction, the importance of follow-up care, and reviewed resources to support Sarah.