Holistic gynecological care of the patient after hysterectomy for malignant endometrial cancer

INTRODUCTION

Malignant endometrial cancer, commonly referred to as endometrial cancer, is one of the most prevalent gynecological malignancies. It ranks sixth among all cancers diagnosed in women worldwide [1, 2]. Endometrial cancer is primarily diagnosed in women during the perimenopausal period, typically after the age of 50; however, a rising incidence of cases has also been observed in women under the age of 45 [3]. Annually, over 420,000 women worldwide are diagnosed with endometrial cancer, resulting in more than 9,700 deaths [1]. In Europe, by contrast, endometrial cancer is diagnosed in more than 2 in 100 women, with approximately 25% of these cases occurring in those of reproductive age. In Poland, it is estimated that over 6,000 new cases of endometrial cancer are diagnosed annually, resulting in ap-proximately 2,000 deaths [4-6]. Endometrial neoplasia results from the continuous and abnormal growth of cells lining the uterine cavity, which is altered by cancerous processes. The precursor to these mucosal changes is prolonged or excessive estrogen stimulation, occurring in the absence of balanced progesterone levels, which are essential for maintaining a eutrophic endometrium. Estrogens play a crucial role in regulating cell proliferation within the endometrium and influencing morphometric changes in the glandular epithelium. In situations where progesterone levels are insufficient, this imbalance can lead to endometrial hyperplasia, which may subsequently evolve into endometrial cancer [7, 8]. The increase in incidence and mortality is particularly pronounced in developed countries, where there is a notable rise in obesity and diabetes. These conditions elevate the risk of developing endometrial cancer by two to four times compared to healthy women [3, 6, 7, 9]. Additionally, there is a threefold higher incidence of endometrial cancer in women with polycystic ovary syndrome and those with congenital mutations in DNA repair genes (such as MSH2, MSH6, and MLH1). Furthermore, a correlation has been identified between hypertension, endometrial cancer, and the pharmacological agents used to manage these conditions [3, 7, 10]. Factors that particularly predispose individuals to endometrial cancer include age, genetic factors, a family history of the disease, nulliparity, dietary habits, and a prior history of gynecological diseases or cancers, such as breast cancer. Additionally, the use of the drug tamoxifen in breast cancer treatment and long-term unopposed estrogen therapy significantly increase the risk of developing endometrial cancer, with estimates suggesting a tenfold increase in risk. The incidence of endometrial cancer is believed to be influenced by various environmental factors [3, 11, 12].
Endometrial cancer is most commonly associated with abnormal uterine bleeding and pelvic pain [13]. Given the projected increase in the incidence of endometrial cancer in the coming years, early detection and accurate diagnosis are critical. Currently, physical examination, imaging studies, and histopathological analysis are employed to evaluate and confirm the diagnosis of endometrial cancer. These procedures provide essential information for selecting and proposing the most appropriate treatment and care plan tailored to the patient’s individual condition. Early detection of endometrial cancer is associated with improved prognosis and a higher likelihood of successful treatment [6, 14]. Therapeutic options typically include hormonal or surgical interventions, often supplemented with radiation therapy or chemotherapy [3, 11]. The selection of treatment is based on the determination of the tumor stage, utilizing classifications established by Bokhman, FIGO 2023, as well as the classification introduced by The Cancer Genome Atlas and ES-GO/ESTRO/ESP 2020 [15-19]. An advanced stage of endometrial cancer qualifies a patient for a hysterectomy, which is a common gynecological procedure and the most frequently performed elective surgical intervention globally [20]. A distinction is made between several types of hysterectomy: partial hysterectomy (removal of the uterine body only), total hysterectomy (removal of the uterine body and cervix), total hysterectomy with bilateral salpingo-oophorectomy (removal of the fallopian tubes and ovaries), and radical hysterectomy (complete removal of the uterus and upper vaginal canal). As a result of advancements in surgical technology, laparoscopy has become a commonplace minimally invasive technique that enables the diagnosis and treatment of various conditions affecting the female reproductive system, including the removal of the uterus [21].
The topic of endometrial cancer, as well as the hysterectomy procedure, including diagnostic approaches and potential treatment regimens, are extensively studied and documented, facilitating a comprehensive understanding and discussion of these issues. However, there are still limited references in the literature regarding the role of midwives, who make a significant contribution to delivering comprehensive care and developing individualized nursing processes. Considering the rising incidence of endometrial cancer and the increasing prevalence of conditions that influence its development, it is essential to raise awareness regarding the care of cancer patients. This support should encompass not only the period of diagnosis but also preparation for surgery and adaptation to altered quality of life. Recognizing the specific needs of patients during hospitalization is essential for optimizing their care and overall well-being. The purpose of this article is to emphasize holistic and continuous care tailored to the individual needs of patients with endometrial cancer during the perioperative period, utilizing WHO-FIC tools, including the ICNP nursing process and the ICF framework.

METHODS

For the purpose of this study, the research method employed was a “case study”, conducted in accordance with the CARE guidelines [22]. Using the aforementioned method, it is possible to demonstrate the ability to provide holistic care for the patient by diagnosing the condition, recognizing the patient’s needs and deficits, and developing an individualized care plan, followed by an evaluation of the interventions implemented. Informed consent was obtained from the patient for participation in the study, along with permission from the facility’s management for the use of medical records. Additionally, approval was granted by the Bioethics Committee for Scientific Research at the Medical University of Gdańsk (KB/408/2024). The study was conducted in September 2024. The study encompassed a detailed examination of obstetric and clinical conditions. Research methodologies employed include observation, direct interviews, and analysis of medical records, such as medical history, fever charts, individual nursing care charts, and vital signs charts. Additionally, C-HOBIC care outcome indicators were used to assess the effectiveness of care provided [23]. The Activities of Daily Living (ADL) scale offers crucial insight into a patient’s functional performance, facilitating an assessment of his or her level of dependence in performing basic daily activities. Conversely, the pain scale, used in the context of continuous comprehensive care and long-term care, allows for a systematic assessment of both the frequency and intensity of a patient’s pain throughout hospitalization. The individual care plan was developed using the ICNP reference terminology available in Polish on the International Council of Nurses website. An effort was made to enhance the care plan for the two diagnoses by incorporating elements from the International Classification of Functioning, Disability and Health (ICF). Both tools are integral components of the WHO-FIC framework [24, 25].

CASE REPORT

The patient, a 67-year-old female, presented with symptoms of abnormal uterine bleeding (AUB) during the postmenopausal period. The patient’s last menstrual period occurred at the age of 53. According to her reports, her menstrual cycles were regular but occasionally characterized by increased heaviness and pain. She has a history of three pregnancies, including two term pregnancies resulting in vaginal deliveries and one ectopic pregnancy. The most recent cytological examination was performed in November 2023, and her last mammogram was conducted in 2022. She was diagnosed with malignant endometrial cancer type 1, classified according to the Bokhman HG scale as high-grade histologically malignant endometrioid adenocarcinoma. The molecular subtype was identified as TP53wt-NSMP, and the clinical-radiological stage was determined to be FIGO stage 1B, indicating an intermediate risk of malignancy based on the ESGO/ESTRO/ESP 2020 prognostic groups. The patient had a history of surgical interventions, including the removal of an ectopic pregnancy with the associated fallopian tube, treatment for deep vein thrombosis, laparoscopic cholecystectomy, and excision of a malignant neoplasm of the left nipple accompanied by lymphadenectomy of the left axilla. Chemotherapy was administered prior to surgery; however, the patient developed bilateral interstitial pneumonia and subsequently experienced a pulmonary embolism during the course of treatment. The patient presented with vitamin B12 deficiency anemia, cardiac arrhythmias, and disorders of lipid metabolism. Additionally, she has been diagnosed with intestinal diverticular disease, gout, and chronic renal failure. The patient is on a permanent oral medication regimen that includes rivaroxaban 20 mg, which was discontinued 24 hours prior to hospital admission; letrozole 2.5 mg (0-1-0); metoprolol 75 mg (1-0-0); trimetazidine 35 mg (1-0-1); candesartan 8 mg (1-0-0); atorvastatin 10 mg (0-0-1); acetylsalicylic acid 75 mg (0-0-1); and calcium carbonate 1 g (1-0-0). Following a comprehensive medical history and diagnostic evaluations, including curettage, the patient was found eligible for a modified radical hysterectomy via the laparoscopic approach, assisted by the Da Vinci robotic system. The procedure included bilateral salpingo-oophorectomy and excision of sentinel lymph nodes, which were pre-labeled with indocyanine green. Upon admission to the ward, the patient’s general condition was assessed as good, with no reported complaints of pain. In evaluating the risk of infection, she was classified in the high-risk group due to her medical history and age. Additionally, in the assessment of the risk for developing thromboembolic complications, she was classified in the maximum risk group. Based on this assessment, perioperative thromboprophylaxis was initiated with enoxaparin, administered subcutaneously at a dose of 60 mg (0.6 ml) before surgery and 40 mg (0.4 ml) after surgery. The patient also received education on gastrointestinal hygiene and preparation prior to the surgical procedure. During the interview, the patient expressed her concerns and fears about the disease and potential complications; however, she showed understanding and acceptance of the recommended medical procedures. As expected, the surgery was completed without complications. In the recovery room following the procedure, the patient’s condition was stable: no bleeding was observed, the urine obtained via the catheter was clear, and the wound dressing remained clean. Fluid balance was maintained, and the patient’s vital signs were closely monitored, with particular emphasis on blood pressure. Due to the pain experienced, intravenous pharmacotherapy was initially initiated, followed by the introduction of oral medication. On the first day after the procedure, the patient was in good general condition, with no concerning changes noted. However, the midwife made an unsuccessful attempt to assist the patient with mobilization, as the patient demonstrated reluctance to get out of bed. Consequently, the patient was informed about the benefits of early mobilization while being given the opportunity to make decisions regarding her care. Later the same day, she began improvement exercises in the supine position, initially with minimal effort, and subsequently undertook to get out of bed. The midwife assisted the patient in mobilizing around the room. Following the removal of the Foley catheter, the patient was able to urinate independently. Pain management and thromboprophylaxis were continued as part of her postoperative care. On the fourth day of hospitalization, a decision was made to discharge the patient, as the wound healing process was progressing well and the patient demonstrated adequate self-care abilities. Prior to discharge, the midwife provided education on proper wound care and dietary recommendations after surgery. Educational brochures were given to the patient to reinforce the information provided.

PLAN OF CARE

An individualized plan of care was developed based on the ICNP classification, ensuring a holistic approach to the patient. This plan was created through the analysis of medical records, observations, and the conducted interview. Additionally, an effort was made to enhance the nursing process by incorporating elements from the ICF. The patient’s self-care abilities were assessed using the ADL scale, in the context of continuous comprehensive care (Table 1), taking into account her age and health status. Additionally, a pain scale specific to continuous comprehensive care and long-term care was used to evaluate the patient’s pain complaints (Table 2).
The assessment of the patient’s self-care abilities through the ADL scale facilitated the identification of specific deficits. Based on these results, targeted supportive interventions were implemented, including assistance with mobility. Additionally, the pain scale provided detailed information regarding the prevalence and intensity of the patient’s pain, enabling the development of tailored interventions that addressed the patient’s individual needs.
The following outlines the nursing process based on the ICNP reference terminology (Table 3).
In addition, two ICF diagnoses are included to enhance the ICNP process, addressing aspects of functioning and activity to support clinical reasoning (Table 4).

DISCUSSION

The primary objective of our study was to present a holistic care plan for a patient following a hysterectomy due to endometrial cancer. The most significant finding of our observations is that, in addition to appropriately selected clinical treatment, a comprehensively planned nursing care approach is equally crucial. The WHO-FIC tools may serve as a valuable and practical resource in supporting the planning of patient care in such a clinical scenario. Accompanying women in gynecological wards is a special form of care provided by midwives. The period of cancer diagnosis and treatment is a particularly stressful time for patients and their families. Research indicates that assisting individuals in coping with various emotional, social, and physical challenges can significantly reduce anxiety and facilitate the processes of diagnosis and treatment. Support in accepting and adapting to a different quality of life may also lower the risk of depression [26]. Therefore, during the diagnostic and therapeutic phases, it is essential to address not only the medical aspects but also the psychological components. This can be achieved by supporting and recommending the use of psycho-oncological counseling, including innovative digital formats that can be accessed in a home environment, thereby enhancing both the comfort and effectiveness of the sessions conducted [27]. In the present case, psycho-oncological support was not provided prior to surgery, which may have contributed to the patient’s subsequent doubts and diminished motivation to mobilize.
It is important to note that recent studies indicate that both morphological and clinical classifications regarding the pathogenesis of endometrial cancer, as outlined by Bokhman and FIGO 2023, are inadequate for providing an accurate and reliable assessment of prognosis and treatment response. To achieve this, the molecular classification introduced in 2013 by The Cancer Genome Atlas (TCGA) should be applied, as it provides a more comprehensive clinical picture of the patient and indicates potential treatment regimens. In the case described, the recommended classification was used in the diagnosis, yielding a more complete understanding of the nature of the patient’s lesions and facilitating the selection of the most appropriate treatment method in accordance with the guidelines of the Polish Society of Gynecologic Oncology [18].
Our patient’s case demonstrates that despite significant medical history burdens and clinical condition – posing a considerable challenge for clinicians who apply the latest therapeutic methods based on the most up-to-date guidelines for treating this type of cancer – these measures alone are not always sufficient. Only the collaboration of an interdisciplinary team can provide the appropriate holistic care necessary to support the patient in regaining a level of functioning that enables self-care. The interventions undertaken by the midwife played a crucial role in achieving the goals set in the care plan.
ICNP is an excellent and modern tool that enables comprehensive perioperative care planning, ensuring a holistic and systematic approach to patient management. Its application allowed for an in-depth analysis of the patient’s condition, facilitating personalized and evidence-based nursing interventions. The use of the ICF for planning and assessing the effects of perioperative care is not widespread and is infrequently implemented. While the ICNP focuses on nursing diagnoses and interventions, the ICF facilitates the assessment of functioning and activities of daily living from a holistic perspective, significantly enhancing the comprehensive approach to addressing the patient’s needs. The tools employed facilitated the enhancement of the patient’s physical and emotional well-being through thoughtfully planned supportive and tailored activities. These activities included educating the patient about the treatment regimen, implementing infection prevention measures, reducing anxiety, and minimizing pain. Furthermore, research on the mapping of ICNP and ICF diagnoses indicates that, although the two tools may overlap, they allow for the assessment of the patient from different perspectives. Considering the need for interdisciplinary care integration, the ICF could complement the standard ICNP, thereby demonstrating essential clinical reasoning for various professions collaborating on the same activities [28].

CONCLUSIONS

The responsibilities of the midwife in the perioperative care of patients with endometrial cancer encompass both medical aspects and psychological support.
Thorough preparation and effective education regarding the correct procedure by the midwife have a direct impact on the success of the intervention and the patient’s recovery process.
It is essential for the midwife to conduct a detailed interview with the patient to establish an individualized approach and plan an effective nursing process.
The midwife, through continuous supervision of the patient following gynecological surgery, is able to detect and respond to the potential emergence of postoperative complications.
The midwife provides support and addresses any questions and concerns, playing a crucial role in the patient’s mental preparation for surgery and self-care at home.
The midwife assesses the effectiveness of the patient’s treatment by performing nursing procedures and administering prescribed analgesics.
Early identification of the patient’s problems and deficits using the ICNP facilitates the development of a clear plan of care, which enhances the quality of care following the hysterectomy procedure and helps to minimize the risk of complications.

Disclosures

This research received no external funding.
The study was approved by the Bioethics Committee of the Gdańsk (Approval No. KB/408/2024).
The authors declare no conflict of interest.

References