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 OB-GYN, who conducted a pelvic exam and transvaginal ultrasound that showed a pelvic mass and an abnormally thick endometrium. Her OB-GYN performed a biopsy on the endometrium which identified Type I 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 postmenopausal 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 I and type II. Type I 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 II is less common. It isn't estrogen-dependent, doesn't involve hyperplasia, and is more aggressive. Type II 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 I 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; blood pressure 124/68 mmHg; heart rate 82 beats per minute; 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/dL and a hematocrit of 29%, findings consistent with mild anemia.

Nurse Taylor: How are you feeling, Sarah?

Sarah: Exhausted and worried. I'm still having bleeding, too.