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Tag Archives: preventive care

  • Vulvar Cancer

    Vulvar Cancer

    By: Suzanne Garcia, CRNP, BSN

    Johns Hopkins School of Medicine & Baltimore City Health Department

            Vulvar cancer includes cancer of the mons pubis, labia majora, labia minora, clitoris, vestibular bulb, and greater vestibular glands. Geographically, it’s most common in Europe, North and South America, and Oceania.1 Women between the ages of 60 and 80 years old are more likely to develop vulvar cancer; however, it may occur in younger women as well.

         The etiology of the disease process is different in these two groups. In younger women, especially those who smoke, have a history of sexually transmitted infections, are immunodeficient, or have a low socioeconomic status are more like to have HPV associated vulvar cancer.These women experience the precursor lesion, vulvar intraepithelial neoplasia (VIN) that is HPV dependent and seldom progresses to squamous cell carcinoma (SCC).2 Women over 60 years old typically develop VIN that is HPV independent and progresses to warty/basaloid SCC.2 HPV independent vulvar SCC arises from lichen sclerosus, lichen planus, or another form of chronic dermatitis.3 From inflammation, to cellular atypia with advancement to VIN and squamous cell carcinoma1, SCC is usually diagnosed early and may present as a mass, scaly patch, plaque, pruritis, or ulcer.3

         Although women between 60-80 years old typically develop HPV independent neoplasia, recommendations for examination and diagnosis include vaginal and cervical colposcopy3 because HPV is present in 86% of precancerous changes in the vulva.1 Cystoscopy and/or proctoscopy may be indicated for invasive disease.3

         Surgery is the mainstay of treatment for early stage disease.3 Evaluation of lymph nodes is necessary if the lesion is >1mm deep, or ≥2 cm from vulvar midline. Furthermore, biopsy of the sentinel node is warranted according to Wohlmuth and Wohlmuth-Wieser (2019) “. . . if the tumor is unifocal, has a diameter of less than 4 cm, and the lymph nodes are clinically negative.” 3(p1260)

        Nodal disease is a predictor of outcome. If the sentinel node is positive, treatment with external beam radiation therapy (EBRT), and possibly chemotherapy with dissection of the inguinal node is preferred.3 Although these patients are less likely to have progressive disease, involvement of at least one node drops the 3-year overall survival rate to 56.2% from the 90% of negative nodal disease per the retrospective AGO-CaRE-1-multi center study. Additionally, the five-year recurrence rate is 37% treatment completion.4

         Vulvar cancer is often diagnosed in women over 60, but some younger women may be affected. HPV is a factor in this group, while it typically arises from prolonged inflammation later in life. However, colposcopy is a mainstay of diagnosis in both groups. Nodal involvement forecasts outcomes.

    References

    1. Merlo, S. (2020). Modern treatment of vulvar cancer. Radiol Oncol, 54(4), 371-376. doi: 2478/raon-2020-0053
    2. van der Avoort, I. A. M., Shirango, H., Hoevenaars, B. M., et al. (2006). Vulvar squamous cell carcinoma is a multifactorial disease following two separate and independent pathways. Int J Gynecol Pathol, 25(1), 22-29. doi: 10.1097/01.pgp.0000177646.38266.6a
    3. Wohlmuth, C., & Wohlmuth-Wieser, I. (2019). Vulvar malignancies: An interdisciplinary perspective. Journal der Deutschen Dermatologischen Gesellschaft, 1257-1273. doi: 10.1111/ddg.13995
    4. Te Grootenhuis, N. C., van der Zee, A. G. J., van Doorn, H. C., et al. (2016). Sentinal nodes in vulvar cancer: Long-term follow-up of the Groningen International. Study on Sentinel nodes in Vulvar cancer (GROINSS-V) I. Gynecol Oncol, 140(1). 8-14. doi: 10.1016/j.ygyno.2015.09.077
  • Lung Cancer Screening

    LUNG CANCER SCREENING: A MAJOR ROLE IN PREVENTATIVE CARE

    By: Jolene Cannaday DNP, AGPCNP-C

               

               On August 1st we observed World Lung Cancer Day, a day of observance that started in 2012 to help raise awareness and promote overall lung health. Many NPs work in primary care where preventative screening plays a major role. The importance of lung cancer screening is part of this preventative mindset. The United States Preventative Services Taskforce (USPSTF) currently has a Grade B recommendation for lung cancer screening via low-dose computed tomography (LDCT) for 50 – 80-year-old adults who have a 20 pack-year smoking history, currently smoke, or have quit smoking within the past 15 years1. The USPSTF recommends that screening be discontinued if a patient has not smoked for 15 years, or if they have health issues that greatly limit life expectancy or limit their ability to have lifesaving surgery or treatments1. When screening a patient’s smoking history remember that one pack-year is the equivalent of smoking an average of 1 pack, 20 cigarettes, every day for one year.  On average when calculating this, I ask patients to think about the greatest number of cigarettes they have smoked daily for the longest period of time, because at times a patient’s smoking history may be varied. 

                Lung cancer was the second most common cancer and the leading cause of cancer-related death among men and women in the United States in 20202.  Screening is an important preventative measure in lung cancer, as many patients with lung cancer presented with metastatic or later disease2.  Lung cancer has 2 main categories of classification. The first classification is non-small cell lung cancer (NSCLC) which includes adenocarcinoma, squamous cell, and large cell cancers. The second classification is small cell lung cancer which is considered the more aggressive of the two major categories and has lower survival rates. Approximately 80% to 85% of lung cancers are in the NSCLC category3. Risk factors for lung cancer include smoking, which accounts for 90% of all lung cancers, and radiation therapy, environmental exposures, family history, race/ethnicity, and other lung diseases4

                Therefore, lung cancer screening is a pertinent discussion to have with your higher risk patients. Ensure that each patient is screened for smoking history, which will help determine which patients to further discuss this key element of preventative care. During the month of August promote lung cancer awareness and discuss lung cancer screening with other colleagues in your practice. Create an atmosphere of prevention and guideline-based care.

    References

    1. S Preventative Services Task Force. Lung Cancer Screening. Published March 2021.Accessed July 10, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
    1. National Cancer Institute. Surveillance, Epidemiology, and End Results Program: Cancer Stat Facts: lung and bronchus cancer. Accessed July 24, 2022. https://seer.cancer.gov/statfacts/html/lungb.html
    2. American Cancer Society. Key statistics for lung cancer. Published 2017. Accessed July 10, 2022. http://www.cancer.org/cancer/lung-cancer/about/key-statistics.html
    3. American Cancer Society. What is lung cancer? Published 2019. Accessed July 10, 2022. http://www.cancer.org/cancer/lung-cancer/about/what-is.html
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