Support Care Cancer (2015) 23:581–600 DOI 10.1007/s00520-014-2427-5


Development of protocol for the management of cervical cancer symptoms in resource-constrained developing countries Ramaiah Vinay Kumar & Suman Bhasker

Received: 29 April 2014 / Accepted: 2 September 2014 / Published online: 16 September 2014 # Springer-Verlag Berlin Heidelberg 2014

Abstract Cervical cancer is the commonest malignancy of women in economically emerging countries. Patients have distressing symptoms from presentation through follow-up or end of life. Cervical cancer imposes significant burden on health care system due to distressing symptoms and associated loss of quality-adjusted life years (QALY). Multitude of drugs and surgical measures in various combinations can relieve these distressing symptoms and various clinical conditions. The protocols and guidelines for alleviation or relief of symptoms by general pharmacological and surgical measures form an important policy subject in planning cervical cancer management program. These protocol and guidelines are based on the mechanism of action of drugs, extrapolation from management of similar symptoms, and clinical situations arising out of other non-cancerous conditions and experience of health care professionals. Therefore, rigorous evaluation of effectiveness of supportive health care services in developing countries is the need of hour. However, evaluation of such protocol and guidelines are not feasible in emerging economies due to resource constraint. Industrialized affluent nations are also not able to implement and further support care guidelines despite its recognition as an integral part of multidisciplinary management of cancer. Aforementioned factors have created blind spot zone of management purview of cervical cancer. Hence, we attempt to develop protocol for management of adverse events of cervical cancer. Symptoms’ and medical conditions’ management guidelines evolved on the basis of empirical clinical practice in community and premier R. V. Kumar (*) Radiotherapy, Kidwai Memorial Institute of Oncology, Bangalore 560029, India e-mail: [email protected] S. Bhasker Radiotherapy, All India Institute of Medical Sciences, New Delhi 110029, India

oncology centers in resource-constrained developing countries has been presented in this short report. This report should not be an end in itself but has to attract attention of policymakers, academicians, researchers, and practitioners toward advancing supportive care needs of cancer patients in low- and middle-income countries (LMIC). Keywords Cervical cancer . Supportive care . Developing countries . Quality of life (QoL) . Adverse events Cervical cancer is the most common cancer in women in developing countries. Disease in these regions of the world usually presents in and beyond the third decade of life. White vaginal discharge, lower abdominal pain, low back ache, and vaginal bleeding are some of the commonest presenting symptoms. Poverty, multiparity, poor genital hygiene, nutritional deficiency, tobacco use, and lower socioeconomic status have been postulated as risk factors for the development of cervical cancer. Sexually transmitted genital infection with high-risk oncogenic human papillomavirus (HPV) has been consistently associated with development of cervical cancer. Biopsy of cervical growth, chest X-ray, cystoscopy, sigmoidoscopy, hemogram, biochemistry, computed tomography of abdomen and pelvis, and positron emission tomography are various investigations sought for staging, prognosticating, and planning therapy. Early cervical cancers are managed by surgical resection and post-operative pelvic radiotherapy. Bulky early cervical cancers and locally advanced cervical cancers (IIb onward) are managed by radical radiotherapy along with weekly cisplatin or carboplatin. Monitoring for weekly hematological and biochemical parameters are mandatory during concurrent chemoradiotherapy. Brachytherapy is an integral part of radiotherapeutic management of cervical cancer and can also be the sole therapy in medically inoperable FIGO stage IA1 disease. Patients with poor performance status,


uremia, and metastatic disease are managed by palliative radiotherapy or best supportive care [1]. Approximately 80 % of global cervical cancer incidents is observed in poor and less-developed regions of the world. Diagnosis of the disease and associated symptoms results in tremendous loss of global quality of life (QoL) of patients with cervical cancer [2]. Patients treated with chemoradiotherapy are prone to develop acute (during chemoradiotherapy), subacute (up to 6 months of radiotherapy), and late (after 1.5–2 years of radiation) adverse events (AE) [3]. Therapy-related and therapy-unrelated AEs along with cervical cancer per se are responsible for the distressing symptoms right from the time of presentation through the survival or end of life [4]. Multitude of issues arises out of cervical cancer demands the attention of skilled oncological professionals from multiple medical and allied health care disciplines [5]. However, resource constraints in terms of manpower, materials, and time on already over-burdened health care system has severely impacted all the aspects of outcome of cervical cancer [6]. Medical team led by physicians/surgeons, in contrary to existing health care situation in developing countries, can easily and effectively manage most of these distressing symptoms and medical conditions by pharmacological and/or surgical measures. Medical and surgical initiatives, mostly palliative and sometimes combined with definitive measures, are directed toward relieving or ameliorating symptoms and medical conditions of cervical cancer patients [7, 8]. Relief of symptoms and accompanying sense of well-being is associated not only with improved QoL but also better treatment compliance, oncological outcome, and survival [9–11]. Therefore, guidelines and protocols designed for symptomatic management of cervical cancer patients is an imperative aspect of policy overlooking planning and implementation of cervical cancer program in developing countries. This papers aims at presenting the cervical cancer symptom management protocol currently practiced in oncological centers in povertyridden LMIC.

Designing the protocol for symptomatic management of cervical cancer in developing countries India has nearly one fourth of global cases of cervical cancers and is disproportionately higher in relation to its share of 17.6 % of world’s population [6, 12]. Cervical cancer is a regular cancer for practicing oncologists, especially of radiation [13]. Distressing symptoms of cervical cancer impairs QoL and can be effectively managed by symptomatic measures. Hospital-based cervical cancer program with in-built symptoms management component has enormous potential and prospects for immense gain in QALY, improving survival, and other oncological end points [9–11]. However, to the best of our knowledge, no literature exists addressing the

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supportive care needs of cervical cancer in both developing and developed countries [14]. We are presenting our account of routine clinical practice based on locally developed protocol in the absence of data on problems associated with cervical cancer and measures adopted to effectively and efficiently resolve them. In our day-to-day clinical experience, these measures appear to be quite effective in palliating the symptoms and medical conditions of cervical cancer. Day-to-day observation of patients’ clinical outcome of particular strategy can be presented as an empirical evidence despite the argument that the randomized controlled clinical trials (RCTs) are gold standard for testing efficacy and safety of particular treatment strategy, and all other study designs are inferior to RCT [15]. Ideally, pharmacological and surgical modalities for symptomatic management along with the structure, process, and outcome of each of developing countries’ health care services delivering supportive care should be rigorously evaluated for relevance, adequacy, accessibility, acceptability, effectiveness, efficiency, and impact [16]. Although RCTs are no doubt the gold standard of evaluation of therapy, they are not without their weaknesses that are beyond the scope of present discussion. Many critics suggest supplementing their findings with evidence from other methodologies, such as epidemiological studies, single-case experiments, and the use of historical controls or just plain clinical experience. Apart from various contentions inherent to RCTs, developing countries face other unique problems [17]. Overburdened health care system due to shortage of resources (man, material, and money) and complexity of delivery of health care services associated with poverty, beliefs, myths, and cultural practices render evaluation of health care services impossible. Evaluation of characteristics of appropriateness, comprehensiveness, adequacy, availability, accessibility, affordability, and feasibility of supportive health care is also impractical due to the aforementioned reason [18]. Unfortunately, not much of research investment on supportive care management of cervical cancer is made even by resourcerich industrial nations [14]. Designing and studying of new treatment protocol, regimes, and devices have outpaced those of supportive care management regime in both developed and developing world. Therefore, supportive care has not gained the much needed attention of policy-makers as compared to that of anti-cancer techniques and technology. Most of the resources are diverted toward development and implementation of technology in oncology, thereby leaving supportive care in abyss of oncological sciences [19, 20]. Hence, we have designed supportive care protocol and guidelines based on our practice in milieu of physicians with diverse treatment philosophy, observation of outcome of patients, day-to-day experiences, and occasionally, empirical or trial-and-error approach. Cancer Therapy Evaluation Program (CTEP) of the National Cancer Institute (NCI) has given general guidelines for symptoms documentation, grading, and management.

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These guidelines have been the bases for our clinical decisionmaking with respect to management of distressing symptoms that are either presenting or the result of anti-cancer therapy [5]. Development of symptomatic management protocol is also encouraged by the following factors: (a) Patients’ expression of satisfactory relief of symptoms by the medications and measures listed in the guidelines; (b) reproducibility of effectiveness of these measures in consecutive patients; and (c) availability, accessibility, acceptability, and affordability of most of the patients in our setup [21–25]. This report aims at presenting our best experience with supportive management of common symptoms of cervical cancer patients in oncology centers in India, a LMIC as per World Bank’s classification of world economies [26].

Framework of development of cervical cancer management protocol The following steps were observed in the development of protocol for management of cervical cancer in two cancer centers of resource-constrained developing countries. Presented cervical cancer management protocol was developed based on the Common Terminology Criteria for Adverse Events (CTCAE) of NCI (Table 1). This protocol involves recognition of AEs and clinical decision-making regarding management of the same by multidisciplinary team of health care practitioners involving mostly physicians and surgeons of different clinical specialties. It has been acknowledged in our clinical setting that nurses play pivotal role in recognition and management of AEs. Trained oncology nurses and other allied health care professionals, when available, do contribute significantly toward management clinical decision-making and execution of AE management protocol [27]. Nursing staff and paramedical staff can recognize grade I symptoms and reassure/refer the patients to oncologists. Patients avoid oncologists’ consultation due to long waiting for mild to moderate AEs until symptoms of AEs become too severe to tolerate, may also benefit from availability of trained nursing personnel. Nurses have also helped health care practitioners to develop this protocol by providing feedback on relief of symptom and QoL with particular line of management. We were able to tailor the protocol based on the satisfactory relief of AEs reported directly by patients or indirectly through incharge oncology nurses to health care practitioners. However, lack of adequate training, deficit of patronage, severe shortage of adequately trained oncology and general nurses, absence of legal framework, statutory restriction on clinical practice of nurses, doctor-patients’ relationship, and dominant role of doctors in direct delivery of health care have resulted in referral of patients by oncology nursing staff to oncologists’ consultation. Reciprocally, with respect to delivery of health care, the nursing staffs in developing countries are equipped


for the tasks of monitoring patients, dispensing, administering, and supervising pharmacological therapy. Assisting health care professionals in various medical and surgical procedures is yet another domain of nursing professionals. Clinical psychologists, dentists, pharmacists, physician assistants, dieticians, therapists, chiropractors, clinical officers, social workers, phlebotomists, physical therapists, respiratory therapists, occupational therapists, audiologists, speech pathologists, optometrists, emergency medical technicians, paramedics, medical laboratory scientists, medical prosthetic technicians, managers of health care services, health information technicians, and other assistive personal and support workers are not available, partially functional in only some aspects of patient care or involved in in-direct patient care in the provincial public sector hospitals due to lack of awareness of role of health care professionals by health policy-makers. Hence, health care practitioners, i.e., doctors, have become principal and sole source of management of AEs in cervical cancer patients. This protocol has been developed by continuously observing successive patients for relief of AEs with particular line of management. Symptomatic patients should be offered an initial pharmacological management followed by same medications in injectable form or another alternative oral or injectable medication. Pharmacological preparations and agents were changed stepwise based on responses of patients. Form of medication can be changed in cases of unresolution of symptoms, i.e., oral syrup or tablets can be changed to oral powder form of medications. Those with breakthrough symptoms were offered sustained- or delayed-release preparation in place of regular ones. Surgical management should be contemplated in patients with progressing grade III and life-threatening grade IV surgical AEs. Pharmacological agents or surgical measures that consistently yielded desired responses were maintained in the line of management and were established as first-line agent/s and part of protocol for those particular AEs. Small subset of patients whose symptoms were unrelieved by those who were intolerant to first-line agents or preferred specifically the second line of management of AEs were offered the second line of AE management. Performance status, disease control, comorbidities, and life expectancy are the other factors that determine suitability of patients for surgical procedures. Grading of adverse events were done based on CTCAE of NCI. CTCAE do not separate individual patients’ subjective perception of AEs that are consequence of therapy and tolerance of patients from the objective stratification based on each of the cutoff criteria. Hence, patients’ management decision necessitates combination of both subjective and objective findings. We were not able to formally collect data for each of the AEs due to constrained resources in our setup. During our observation period of 4 years, most of the patients report relief


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Table 1 Common Terminology Criteria for Adverse Events reporting v4.0 classification of adverse events CTCAE grade

Degree of symptoms

Clinical presentation of symptoms Interventions

Professionals needed for interventionsc

Grade 1


Grade 2


Grade 3

Severe non-lifethreatening

Grade 4


Clinical or diagnostic observation Not indicated; reassurance; referral Trained oncology nurses and only to treating physicians in cases of other allied health care management difficulties/doubts/ professionals persistent or progressing AE Treating physicians/surgeons Minimal symptoms, limiting age- Local or non-invasive interventions appropriate instrumental ADLa Treating physicians and/or Disabling; limiting self-care ADLb In-patient care and/or elective surgical care surgeons; specialist surgeon has to be consulted for specialized treatment and surgery Urgent surgical intervention Exclusively by specialist surgeon indicated

Grade 5


Source: CTEP [5] a

Instrumental ADL refers to preparing meals, shopping for groceries or clothes, using the telephone, managing money, etc.


Self-care ADL refers to bathing, dressing and undressing, feeding self, using the toilet, taking medications, and not bedridden


Other and allied health care professionals mostly work under the supervision of physicians or surgeons in developing countries due to lack of resources to train them in oncology units of developing countries

of AEs and improvement of QoL with this protocol. However, occasional patients with recalcitrant symptoms are reassured or referred to specialists (including palliative care) for management of their symptoms. Another unique feature of this protocol is its feasibility in the resource-scarce developing countries.

Management of symptoms in cervical cancer CTCAE reporting of NCI has listed a whole spectrum of signs and symptoms related and unrelated to cancer and cancerdirected therapy. Each of the symptoms has been graded 1 through 5. Severity of symptoms, intensity of care, and need for invasive specialized procedure increases with the grade of AEs [5]. AEs can manifest as an isolated complaint, sign, abnormal laboratory value, or a medical condition. Baseline history-taking and investigations would accurately record the incidence and severity of AEs after the presenting complaints have been partially or completely resolved by medical or surgical measures. The protocol for management of AE was developed based on the CTCAE of NCI. Each of the AEs is grouped with its corresponding symptoms, possible causes, differential diagnosis, and management. Asymptomatic isolated AE detected by clinical or radiological investigations are classified as grade 1 and are best managed by serial observation without the need for any additional investigations or interventions. Grade 2 through 4 AEs need interventions ranging from pharmacological measures to elective or emergency surgical management (Table 2). Patients presenting with AEs were usually

prescribed symptomatic medications that are inexpensive and easily available at the local pharmacy. Patients’ chemotherapy dosage, schedule, prechemotherapy investigations, and radiotherapy plan were all rechecked at radiotherapy review. Patients with CTCAE grade 2 AE were prescribed with symptomatic medication on outpatient basis without prescribing any further investigations. Most patients of grade 2 AE are subjected to further investigation and change of medications and/or line of management if the symptoms are unresolving or progressing. Patients with CTCAE grade 3 AE are usually hospitalized for one or combination of the following: intravenous fluid, interruption of anti-cancer therapy, empiric/definitive antibiotics, supportive pharmacological and surgical measures. Deteriorating/unrelieved AE warrant hospitalization, stopping cancer-directed therapy, further investigation of patients, and change of line of supportive care management. Cervical carcinoma patients with chronic renal failure may not benefit from measures to relieve their uremia, if it exists at presentation, and should always be given options of both best supportive care and percutaneous neprostomy or dialysis. Empirical pharmacological treatment is started at the outset of any of distressing AEs expect in cases where emergency surgical intervention is contemplated. Drugs prescribed were easily available, inexpensive, and should have minimal side effects least the risk of non-compliance and subsequent default from anti-cancer therapy. We were not able to elucidate the exact duration of administration of supportive care medications. In general, they were prescribed until complete resolution of symptoms. Addition of another drug was the usual practice for patients whose


Swelling of unilateral (U/L) or bilateral (B/L) lower limbs, external genitalia

High-grade fever, mouth ulcers, Post-chemotherapy loose stool, pain abdomen

Febrile neutropenia

Hematinics, packed blood cell transfusion (iron, folic acid, and multivitamin supplements) in case of malnourishment, blood loss and post-chemotherapy Defer chemotherapy or decrease the dose in subsequent cycles Measures to resolve renal failure

Blood loss, renal failure, bone marrow suppression after chemotherapy

Clinical pelvic examination Fibrosis of lymphatics and (CPE), general physical lymph nodes postexamination (GPE), radiotherapy, primary/ Ultrasound—abdomen and recurrent extensive lymphatpelvis (USG-AP) and/or ic and lymph node disease computed tomography of abdomen and pelvis (CTAP), FNAC of lymph node

Deep-vein thrombosis, filarisis, Best supportive care/palliative chemotherapy, analgesics, palliative chronic obstructive renal care referral in case of recurrent failure disease Limb elevation by pillow at night, limb stocking for postradiotherapy Palliative radiotherapy for paraaortic lymph node swellings Avoid rapid movement of limbs, heat bathing, sauna, constricting clothing that may obstruct lymph flow

Intravenous antibiotics (third generation cephalosporins and metrogyl) in case of proven febrile neutropenia Adding anti-pseudomonal penicillins (piperacillin and tazobactum combination), newer generation β-lactam antibiotics (imipenem, meropenem) and anti-fungal (fluconozole) or Intravenous antibiotics (ciprofloxacin and metrogyl) empirical antibiotics followed by antibiotics guided by C&S results or local prevailing anti-microbial and sensitivity patterns Anti-pyretics, cold sponging, maintaining strict aseptic precautions Take care of other associated symptoms and conditions

Step-by-step management of conditions according to severity of AE


Hemogram, biochemisty (RFT, Community-, hospitalLFT, SE), throat swab, chest acquired, and other cancerX-ray, culture and sensitivity associated infections (C&S) of stool, urine, throat, blood, and vaginal discharge (as indicated)

Tiredness, fatigability, lethargy Bleeding per vagina, Hemogram (HMG), renal obstructive renal failure due function test (RFT), serum to growth, chemotherapy electrolyte (SE), liver function test (LFT)






Table 2 The management of AE (clinical symptoms, signs, situation, and conditions) of carcinoma cervix patients undergoing chemoradiotherapy or radiotherapy in the developing countries settings

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Decreased hearing Varying degree and nature of pain abdomen

Dull aching or colicky pain abdomen, asymptomatic


Hearing impairment

Pain abdomen


Table 2 (continued)

Asymptomatic grade I—observation alone U/L and B/L HUN with uremia and good urine output Anti-spasmodics, double—J (DJ) stenting, forced diuresis U/L and B/L HUN with uremia and poor urine output

Hearing aids, no further oto-toxic drugs and chemotherapy

Do not cross leg while sitting/sit more than 30 min in the single position.

Step-by-step management of conditions according to severity of AE

GPE, CAE, CPE, USG and/or External compression, CT-AP, RFT, SE, HMG, encirclement, posturology referral for invasive radiotherapy fibrosis of lowinterventions er or asymptomatic

Age-related hearing impairment


Initial trial of symptomatic supportive medications consist of anti-gastric acid medications (ranitidine, pantoprazole), anti-spasmodics (hyoscine), combination of synthetic opioids and anti-pyretics-analgesics (tramadol + paracetamol) Add non-steroidal anti-inflammatory drugs (NSAIDs) for incomplete but significant pain relief Addition of steroids for pain originating from local inflammation in selected cases Antibiotics for infection (as mentioned for infections and febrile neutropenia for details) Non-infective and infective cystitis and proctitis (refer to management of these conditions) HUN (refer to management of HUN) Pyometra (refer to management of pyometra) Bowel irritation and inflammation (refer to management of these conditions) Other pain medications

Pure tone audiometry


Cancer per se, super-added in- Clinical abdominal examination includes per fection, cystitis, proctitis, rectal and per vaginal hydro-uretero-nephrosis examination (CAE), CPE, (HUN), pyometra, bowel irGPE, USG-AP if symptoms ritation, and inflammation are recalcitrant to initial trial due to infection, chemoraof symptomatic supportive diotherapy medications

Cisplatin-induced sensory neural hearing impairment


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Burning micturation, urinary retention, hematuria, discomfort, urgency, frequency

Same as above

Non-infective cystitis

Infective cystitis

Community-, hospitalFever of varying grades and acquired, and other cancerduration, loose stool, pain associated infections abdomen, burning micturation, toxic symptoms


Community-acquired, urinary catheter-related

Chemoradiotherapy, invasion of bladder mucosa by cervical growth

Stenosis/obstruction of endocervical canal and external uterine os

Pain abdomen, asymptomatic





Table 2 (continued)

Urine microscopy, urine C&S, urology referral for incalcitrant, and recurrent infection

Increasing severity and intractable symptoms warrant cystoscopy

Anti-spasmodics, DJ stenting, percutaneous nephrostomy or hemodialysis if DJ stenting fails U/L and B/L HUN without uremia Anti-spasmodics, double—J (DJ) stent, forced diuresis

Step-by-step management of conditions according to severity of AE

Urine alkalinizing agents (disodium hydrogen citrate) Urinary analgesic and anesthetics (phenazopyridine) Urinary anti-spasmodics (flavoxate) Urinary anti-septics (nitrofurantoin and methenamine) Plenty of oral fluids Symptomatic treatment as mentioned for non-infective cystitis Antibiotics therapy as described for the management of infection and

Infective cystitis

Non-infective cystitis

Initial symptomatic treatment with anti-pyretics Empirical broad-spectrum antibiotics (combination of ciprofloxacin and metrogyl) based on local prevailing anti-microbial and sensitivity patterns after collecting biological specimen for C&S C&S-guided antibiotic therapy in case of fever unresolved with empirical antibiotics Local anti-septics (betadine) and anti-fungal (clotrimazole) vaginal pessaries

Hydro-/hemo-/hemo-pyometra Asymptomatic grade I—observation alone Pyometra drainage by sounding the uterine canal through external uterine os Antibiotics (refer to management of infection, febrile neutropenia for guide on antibiotics therapy)


Hemogram, biochemisty (RFT, Febrile neutropenia LFT, SE), throat swab, chest X-ray, culture and sensitivity (C&S) of stool, urine, throat, blood and vaginal discharge (as indicated), peripheral smear, physician referral



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Pain abdomen, loose stool, Chemoradiotherapy increased frequency of stool

Sensation of fullness of Obstructive chronic renal abdomen, objective failure, constipation, frozen distension, anorexia, nausea, pelvis due to extensive vomiting cervical cancer

Passage of unformed or abnormally liquid stools at increased frequency

Bleeding through anal canal

Bowel irritation and inflammation

Abdominal distension/bloating/ dyspepsia/flatulence

Loose stools

Rectal bleeding


Radiation-induced, anal and rectal acute and late effect


Chemoradiotherapy inducedHistory taking, GPE, CAE, bowel and anal canal toxicistool for C&S ty, gastro-enteritis

CAE, RFT, USG-AP, serum electrolyte, erect abdominal X-ray


Chemoradiotherapy, nutritional Per-rectal examination (PRE) deficiency

Burning sensation and pain during defecation and PRE, tenesmus, bleeding per rectum

Non-infective proctitis




Table 2 (continued)

Proctitis, hemorrhoids

Chemoradiotherapy induced bowel irritation, gastritis, gastroenteritis and paralytic ileus

Infective gastroenteritis

Constipation, hemorrhoids, fissure and fistula



Anti-motility drugs (loperamide) for chemoradiotherapy-induced diarrhea Antibiotics (ciprofloxacin and metronidazole) in case of foulsmelling associated with mucus or diarrhea non-responsive to antimotility and anti-secretory drugs. Definitive antibiotics based on results of C&S

Anti-gastric acid agents, prokinetics (domperidone, metaclopramide), 5-HT antagonists (ondensetron), anti-spasmodic agents (hyoscine), multivitamins Measures to rectify uremia, gastroenteritis, gastritis, paralytic ileus Best supportive care in case of uremia, metastasis, and extensive disease

Anti-gastric acid agents, antispasmodics, opioids anti-biotics or NSAIDs (selective use only), probiotics, intravenous fluids, multivitamins

Multivitamins Xylocaine jelly for local application Laxatives (ispaghula, liquid paraffin) Antibiotics in cases of suspected infections Sitz bath In cases of bleeding per rectum (refer to management of rectal bleeding) Analgesics

febrile neutropenia except the initial empirical urinary antibiotic is norfloxacin instead of ciprofloxacin and metrogyl

Step-by-step management of conditions according to severity of AE

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Abdominal distension, rigidity, As a complication of intraguarding, pain abdomen cavitary brachytherapy (ICBT), secondary to paralytic ileus

Colonic perforation

Radiation cystitis, bleeding cervical growth invading bladder lumen, infective cystitis

Blood in urine, urinary retention due to blood clots





Table 2 (continued)

Discoloration of urine due to medications and vegetables


Pharmacological measures as mentioned in the management of rectal bleeding Continuous bladder irrigation with Rusch three-way silicon Foley’s catheter with 0.9 % saline and hemostatic drugs Bladder irrigation with 1 % alum solution Bladder irrigation with 10–40 % formalin under spinal or general anaesthesia Radiological or surgical ligation of feeding vessels Antibiotics in cases of infection

Synthetic vitamin K3 compound (Gynae CVP), anti-fibrinolytics (tranexemic acid), antihyaluronidase (ethamsylate), hemocoagulase (botrophase)— one or combination of the above agents Fresh frozen plasma in case of frank bleeding Entofoam 10 % (hydrocortisone) enema or foam Formalin retention enema (0.5–4 %) Endoscopic fulguration Hematinics (multivitamin and iron supplements), blood transfusion as needed Antibiotics in cases of infection Surgical opinion for bleeding hemorrhoids

Step-by-step management of conditions according to severity of AE

CAE, Abdominal girth Paralytic ileus after Ryles’ tube aspiration charting, erect abdominal Xchemotherapy, sub-acute in- Potassium supplement ray, USG-AP, monitoring SE testinal obstruction Intravenous fluids Total parenteral nutrition Diagnostic and therapeutic paracentesis Laparotomy and repairing of perforation

Urine microscopy, C&S, cystoscopy


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Swelling of supraclavicular lymph nodes, b/l pedal edema

Hard stools, difficulty passing stools, fecal impaction, failure to pass gas and stool

Continuous dribbling of urine or white discharge per vagina

Epigastric burning sensation and pain

Symptoms of fullness, nausea, vomiting, pain abdomen

Bleeding per vagina


Lymph node pain and swelling


Incontinence of urine

Gastritis/gastroesophageal reflux (GERD)


Bleeding per vagina

Table 2 (continued)

Cervical growth, infection, recurrent disease, postradiotherapy spotting Tear of vagina during intracavitary brachytherapy



Vesico-vaginal fistula due to growth, recurrence or chemoradiotherapy

Extra-luminal compression of rectum by cervical growth, cisplatin-induced

Metastatic disease



Step-by-step management of conditions according to severity of AE

Gastritis, GERD


HMG, BCM, CAE, Blood pressure monitoring

Exacerbation of preexisting GERD, gastritis and rarely cardiac toxicity

Antibiotics in cases of infection Synthetic vitamin K3 compound (Gynae CVP), anti-fibrinolytics (tranexemic acid), antihyaluronidase (ethamsylate), hemocoagulase (botrophase)— one or combination of the above agents Anxiolytics, intravenous fluids

Anti-emetics (hysocine, diphenhydramine, metoclopramide, ondasetron, dexamethosone, benzodiazepines, prochlorperazine) Low-fiber, low-fat, low-residue food

Agents to reduce gastric acid secretion (ranitidine, pantoprazole), antacids (aluminium hydroxide, magnesium hydroxide).

Urinary incontinency of old age Foley’s bladder cateterization Antibiotics for any infection Radiotherapy or chemoradiotherapy for cervical cancer Best supportive care for recurrent disease

Paralytic ileus, sub-acute intes- Manual evacuation of impacted tinal obstruction stools Laxatives Bisacodyl (proctoclysis) enema and suppository

Clinical suspicion, X-ray, manometry and gastric emptying scan

CAE, upper gastrointestinal endoscopy

As for fistula, urological evaluation


FNAC of lymph node swelling Infection, inflammation, second Analgesics primary neoplasm Palliative radiotherapy and chemotherapy for good performance status patients Best supportive care Limb elevation and stocking for lymphedema


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Altered taste sensation

Bacterial and fungal infections Vaginal fluid for C&S, HMG, White discharge per vagina BCM (WDPV), itching, pain, pain during per vaginal examination Continuous dribbling of urine, excoriation of external genitalia skin



Head and neck examination

Post-chemoradiotherapy vaginal mucositis

Infection- and drug-associated


Intestinal perforation

Radiation proctitis


De novo fistula due to disease, CAE, instillation of saline and Incontinence of urine recurrence disease, methylene blue dye into chemoradiotherapy bladder and detection of the

Cisplatin- or carboplatininduced



Chemoradiotherapy, uremia

Sensation of impending vomitus and vomiting

Nausea and vomiting

CAE, X-ray erect abdomen, USG-AP, HMG, BCM, monitoring SE

Abdominal pain and distension Cisplatin-induced

Preexisting before the diagnosis CAE, sigmoidoscopy, surgical of cancer referral


Intestinal obstruction/paralytic ileus

Hemorrhoids, fissure, and other anal Bleeding PR, pain during pathology defecation


Table 2 (continued)

As for incontinence of urine

Betadine vaginal pessary Clotrimazole vaginal pessary Oral antibiotics and anti-fungal (fluconazole) for unrelieved and exacerbating symptoms

Reassurance Soda-salt gargle Dietary flavoring by addition of lemon, tamarind and other sour and bitter vegetables

Anti-emetic medications Management is as for uremia if related to obstructive chronic renal failure

Be vigiliant about intestinal perforation secondary to ileus Rest of the measures are as for colonic perforation except the laparotomy

Surgical intervention after the completion of chemoradiotherapy Precautions should be taken to avoid injury during rectal marker insertion for cervical brachytherapy dosimetry Laxative and xylocaine jelly for defecation pain during chemoradiotherapy

Hematinics (multivitamin and iron supplements), blood transfusion and plasma expanders as needed Vaginal packing after Foley’s urinary cateterization Surgical suturing of vaginal tear if blood continues to trickle even after vaginal packing, large vaginal tears

Step-by-step management of conditions according to severity of AE

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Uneasiness, lack of well-being Disease, therapy, psycho-social Cervical cancer staging investigations, specific investigations as guided by signs and symptoms

Varying degree and nature of pain


Discoloration of skin, burning and pain, ulceration of skin


Chest pain

False passage

Radiation dermatitis


Uterine sounding for central tandem insertion during placement of brachytherapy applicators

C&S of ulcer

CAE, monitoring abdominal girth hourly, erect abdominal x-ray, USG-AP, monitoring for any new signs and symptoms

Metastatic lung disease, cardiac X-ray chest, ECG, conditions cardiothoracic referral

Disease per se and its therapy


Subjective feeling of tiredness

Reassurance In-patient admission and intravenous fluids Specific treatment based on the diagnosis Empirical intravenous combination antibiotics with ciprofloxacin and metronidazole

Infection, progressive disease, end-organ failure

Wearing loose cotton clothings Gentian violet paint for ulceration Antibiotic therapy if wound is infected or non-healing

Deferring of brachytherapy applications Rest Hemostatics and antibiotics as needed Laparotomy and closure of any visceral perforation if there exists a one

Analgesics Palliative chemotherapy for metastatic disease Cardio-thoracic opinion for other conditions

Reassurance, exercise therapy, rest, stress reduction, health diet rich in proteins, minerals and plenty of fluids

Discontinuation of drugs, blood transfusion and chemotherapy Administering drugs after test dose Hydrocortisone and diphenhydramine/pheniramine maleate intravenous bolus injection Restart blood transfusion and chemotherapy slowly under strict vigilance

Step-by-step management of conditions according to severity of AE




Infusion reaction to blood transfusion, drugs and chemotherapy

same by vaginal swab, cystoscopy Monitoring vitals

Shivering of body







Table 2 (continued)

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Development of protocol for the management of cervical cancer symptoms in resource-constrained developing countries.

Cervical cancer is the commonest malignancy of women in economically emerging countries. Patients have distressing symptoms from presentation through ...
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