Perioperative care of a patient with ovarian cancer

INTRODUCTION

Ovarian cancer is the second most common cancer of the female genital organs, accounting for 5% of all malignant tumours in women [1]. Approximately 3500 new cases are reported each year in Poland. It occurs mainly in the peri- and postmenopausal periods, and the risk of developing the disease increases with age. It is one of the cancers with the most inauspicious prognosis, as more than 2000 women die each year in Poland [1] due to the delay in diagnosis, be-cause of the presence of nonspecific and paraneoplastic symptoms.
Epithelial neoplasms account for about 90% of ovarian cancers [2]. Somatic epithelial cells, non-epithelial cells, and germ cells provide the substrate for tumour development. Among epithelial neoplasms, we can include benign, borderline malignant, and malignant tumours. Non-epithelial neoplasms, on the other hand, include tumours originating from the primary germ cell, tumours of the genital cords and stroma of the ovary, and various non-specific tumours [3]. Genetic factors, such as carrying mutations in the BRCA1 or BRCA2 genes, which increase the risk of the disease by 40% and 18% over a lifetime, respectively, predispose to the pathology in question [4]. The incidence also increases if there is a family history of hereditary breast and ovarian cancer syndromes and nonpolyposis colorectal cancer, e.g. Lynch syndrome [5, 6]. Other important factors are childlessness, infertility, prolonged ovulation stimulation, unsuccessful attempts at IVF (in vitro fertilisation), and the use of hormone replacement therapy. On the other hand, multiple births and breastfeeding are considered protective factors [2, 5]. The use of oral hormonal contraception reduces the risk of the disease by inhibiting ovulation [2, 7]. The early stages of ovarian cancer are not associated with characteristic clinical symptoms. They are instead gastrointestinal problems including bloating, indigestion, constipation, nausea, and vomiting. Most symptoms occur as the tumour enlarges and compresses adjacent tissues and organs, but they are non-specific and may suggest other benign conditions. The large size of the tumour causes pelvic pain, enlargement of the abdominal girth, a feeling of heaviness, frequent urge to push on the bladder, and polyuria [3, 8].
Diagnosis is very difficult due to the lack of screening tests in this direction, which makes it very common to detect cancer at a late stage. The primary diagnostic method is a gynaecological examination, further expanded by imaging studies such as transvaginal and transabdominal ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) scans. They allow us to learn more detailed information about the size of the tumour, its location, and possible infiltration of other structures [9, 10]. A key role includes the determination of tumour markers: CA-125, HE4, and calculation of the ROMA (risk of ovarian malignancy algorithm) algorithm. These tests make it possible to isolate patients with a high risk for the disease. In the early stage of the disease, HE4 levels are more often elevated than CA-125 antigen, which allows a quicker diagnosis [5, 9, 11]. Histopathological examination is used to make a diagnosis, determine whether the lesion is cancerous, and the type and degree of malignancy. The material is taken during surgery to remove the tumour [9, 12]. There are 2 types of ovarian cancer. Type I includes serous, mucinous, endometroid, and clear cell carcinomas. They are usually limited to one ovary, distinguished by slow growth and a low tendency to metastasize. Type II, on the other hand, includes sarcomas, low-differentiated serous carcinomas, low-differentiated endometroid carcinomas, and undifferentiated carcinomas. They are characterised by rapid growth and high aggressiveness [11]. Prophylaxis for female BRCA1/2 gene mutation carriers includes surgery to remove the adnexa, after the end of childbearing, preferably before the age of 40 years [9, 12, 13].
The main treatment for ovarian cancer is combined management, i.e. surgery and systemic chemotherapy. This treatment gives us the best prognosis [14]. The extent of surgery depends on the clinical stage, determined by the FIGO scale. The goal of the surgery is to completely cytoreduce the tumour, assess the stage, and make a definitive diagnosis [15]. Such a major procedure is often associated with the need for extensive, multi-organ, and multi-hour surgery. Therefore, such procedures should be with the participation of a team of qualified gynaecological oncologists, oncological surgeons, and experienced anaesthesiologists, as well as midwives and physiotherapists during the recovery period, which will provide the patient with a fully comprehensive treatment. Low-grade surgery (I-IIA) consists of bilateral removal of the adnexa, hysterectomy, resection of the greater web, collection of fluid for cytological examination, and collection of peritoneal swabs [5, 16]. For patients who wish to preserve fertility, the uterus and second ovary can be left as long as the lesion is limited to one ovary, without infiltration of other structures [17]. Patients in the advanced stage of the disease, in whom it is not possible to remove all macroscopic foci, should have an optimal cytoreduction performed, which allows the lesion to remain no larger than 1 cm in diameter. Inability to perform this procedure immediately qualifies patients for neoadjuvant chemotherapy [5, 17]. Neoadjuvant chemotherapy follows a typical regimen with paclitaxel and carboplatin along with bevacizumab in FIGO stage III and IV patients [5]. After several courses of chemotherapy with positive results, deferred surgery is performed, and the remaining chemotherapy is administered [15, 17]. This allows for a less invasive procedure and reduces postoperative complications [5]. Most patients have an indication for systemic treatment, with the exception of patients with IA and IB according to the FIGO scale, in whom postoperative chemotherapy is abandoned [5, 15, 16]. It is important to perform CT scans as a method of evaluating surgical results before scheduling courses of chemotherapy. In patients with IC and IIA diagnoses, administration of platinum derivatives (carboplatin or cisplatin) and intravenous toxoids is done in 3 or 6 cycles every 21 days. For stage IIB-IV diagnoses, patients are prescribed paclitaxel and carboplatin for 6 cycles. Administration of paclitaxel requires premedication with steroids, H2-receptor blockers, and antihistamines. After optimal cytoreduction, chemotherapy is administered via the intraperitoneal route. After achieving remission, patients should have follow-up examinations every 3 months for 2 years, then every 6 months for 5 years, and then every 12 months as prescribed by the doctor [5, 16].
Ovarian cancer is characterised by frequent recurrences; therefore, it becomes a chronic disease for many patients. The periods between the recurrence are increasingly short and more resilient to the cytostatics [5]. Treatment of relapses depends on the sensitivity of the cancer to platinum derivatives. Tumours are divided into platinum-resistant (when the tumour progresses during first-line treatment), platinum-resistant (recurrence within 6 months after completion of first-line treatment), partially sensitive (recurrence within 6-12 months), and highly sensitive (recurrence after more than 12 months) [15]. In systemic treatment for patients with ovarian cancer, PARP inhibitors – olaparyb, niraparyb, and rukaparyb – are becoming increasingly important. Their action is to induce double-stranded DNA breaks in tumour cells, resulting in cell cycle arrest and tumour cell death. The best treatment effects are observed in patients with the BRCA1/2 gene mutation. Olaparib therapy is provided in Poland and is started 8 weeks after the last administration of platinum-based chemotherapy. If there is no response to treatment after 3 or more lines of chemotherapy, olaparib treatment can be administered as monotherapy. Recent results show that in patients with ovarian cancer without BRCA1/2 mutations, PARP inhibitors are still relevant in therapy, but with lower efficacy [5, 15, 18]. Angiogenesis inhibitors such as bevacizumab can also be used to treat recurrent platinum-sensitive ovarian cancer in women who have not received first-line therapy [18].
The midwife’s care during the perioperative period is crucial, as they provide comprehensive care during the recovery process. Their tasks include monitoring the patient’s condition, pain management, emotional support, and providing information on postoperative care to ensure maximum comfort and support for the patient. The postoperative period involves several nursing issues. The midwife controls the following: the patient’s consciousness, parameters of general condition, healing of the postoperative wound, the amount and type of fluid in the drain, diuresis, indicators of acid-base balance, and the level of pain intensity [19]. The holistic care of the midwife has a direct effect on negating discomfort and improving the health of the client.
In an effort to improve care for women undergoing treatment for ovarian cancer, we decided to expand our analysis to include the C-HOBIC (Canadian Health Outcomes for Better Information and Care) quality of care indicators. C-HOBIC is an indispensable tool in assessing the quality of obstetric care, allowing for a holistic view of the treatment process. In our article, we use the C-HOBIC indicators to accurately assess the effectiveness of treatment and the availability of innovative approaches, such as PARP inhibitors. The interpretation of the indicators covers key areas such as assessment of the patient’s ability to self-care and their level of fitness, associated with extensive surgery using the ADL scale (The Basic Activities of Daily Living). The ADL scale was used as an indicator of a person’s functional status for home care (Table 1). This scale assesses the patient’s ability to move, eat, control physiological activities, and maintain body hygiene. The Basic Activities of Daily Living Rating Scale was developed by American gerontologist Sidney Katz. Inability to perform basic activities means total dependence and the need for constant care. The scale was scored on a scale of 0 to 6, where individual scores were as follows: 0 – independent, 6 – totally dependent. Assessment results using the ADL scale can be transferred to the ICNP system. The pain assessment scale for the area of continuous comprehensive care and long-term care was used to monitor pain (Table 2). It assesses 2 aspects: the frequency with which the patient complains or shows evidence of pain in recent days, and the intensity of pain on a scale of 1 to 3, with 1 indicating mild pain and 3 meaning sometimes terrible unbearable pain. Another evaluated area of symptom management was the nausea rating scale (Table 3). The scale was rated from 0 to 4, where 0 means no nausea and 4 means incapacitating nausea. These rating categories are an integral part of our study to provide the reader with a comprehensive perspective on the quality of obstetric care in the context of ovarian cancer [20].

MATERIAL AND METHODS

The study used a qualitative “case study” research method, which includes a description of the patient’s clinical condition, for in-depth analysis and evaluation. Informed consent was obtained from the patient to participate in the study. The management of the facility gave permission to use medical data. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Independent Bioethics Committee for Research at the Medical University of Gdansk (NKBB/650/2023) for studies involving human subjects. In addition, research techniques such as interview, observation, physical examination, and analysis of medical records were used. An interview is a conversation with the patient to obtain information that may be relevant to hospitalisation. Observation is the investigation of remarks, which can also provide necessary information. Attention should be paid to facial expressions, gestures, tone of voice, and emotions. The patient should be observed during the interview. Analysing the records involves carefully reading the documentation and selecting the most relevant information from it. This information is needed to determine the category of care, choose the appropriate treatment method, and prevent adverse events [21]. A physical examination of the patient was also performed. Abdominal palpation and gynaecological examination with a thorough evaluation of the adnexa were performed. The patient’s vital parameters – blood pressure, pulse rate, body temperature – were also measured. The C-HOBIC care outcome indicators were also used to describe the case [22]. As a result of the documentation analysis, diagnoses and appropriate nursing interventions were established. During treatment, these interventions were practiced, and on the last day, an evaluation of the nursing process was conducted in accordance with ICN guidelines. The result of the evaluation was a nursing diagnosis indicating progress or a state of no change. Care plans were developed based on ICNP^® reference terminology [23], formulating diagnoses and interventions according to the ISO 18104:2014 standard [24]. Based on this, care plans were created using an online tool available on the International Council of Nurses website [25] and the ICNP^® dictionary in Polish [23].

CASE STUDY

The patient, age 42 years, was admitted as an elective patient to the gynaecology department for a left ovarian tumour for surgical treatment. Prior to surgery, a comprehensive diagnostic workup was performed, including laboratory and imaging studies. As part of the laboratory tests, blood was drawn for analysis, including evaluation of tumour markers (ROMA algorithm: HE4 and CA-125, resulting in CA-125 320 U/ml and HE4 289 pg/ml), which allowed for a comprehensive assessment of the risk of ovarian cancer. The imaging study included a thorough ultrasound examination, as well as abdominal CT and MRI scans. The patient was issued a DILO card (from Polish: Karta diagnostyki i leczenia onkologicznego, ang. oncology diagnosis and treatment card). After testing, the patient was qualified at the hospital clinic for admission to the gynaecology department for abdominal surgery.
A medical interview was conducted. The patient’s status after undergoing laparoscopic removal of left ovarian cyst in 2010 and after cystectomy of the uterine cavity on 11.01.2023 was as follows: does not use any medications; allergies or and chronic diseases denied; a history of nicotinism and no hepatitis vaccination; consumes an easily digestible diet; blood type B Rh (–) (negative). In addition, in order to more fully understand the context of the patient’s health, a detailed history of genetic diseases present in the family was taken. During the interview, the patient did not report information regarding her family history of inherited diseases. The patient was also asked about the potential presence of cancer or other hereditary conditions. The patient had no knowledge of possible genetic predisposition to diseases. However, it should be noted that the lack of access to the patient’s full genetic history may affect the full health risk assessment and follow-up care strategy. In addition, the patient denied that she was brought in for additional genetic testing (including evaluation for the presence of BRCA1 and BRCA2 mutations). The patient lived with her family and described her housing conditions as good. The patient was calm, composed, and accepted the fact of hospitalisation. Verbal contact was preserved, and she oriented herself to the place and time. She moved around independently, performed hygienic activities, and ate meals. The patient reported constipation, bloating, decreased appetite, polyuria, and lower abdominal pain of a stabbing nature, which was frequent, severe and requiring treatment. Her menstrual cycle was irregular, and bleeding was painful and heavy. She had her last gynaecological examination on 11/01/2023. After taking a history, blood was drawn for laboratory tests.
More precise preparation for the surgery was carried out, which included answering all the questions that bothered the patient, informing her about the hygiene before the surgery, about the need to continue fasting, and about the preparation of the surgical field. The midwife also ensured that the patient had adequate rest and sleep before the operation. She provided information on the procedure and the use of sedation drugs, and administered these drugs on the doctor’s orders. The patient was given Nomefren 0.0005 g and Relanium 0.005 g in the evening, and anticoagulant prophylaxis was administered. On the day of the operation, the midwife reassured and surrounded the patient with care, did not leave her alone, encouraged her to ask questions, and assessed her general condition and her well-being, inserted a Venflon, and connected the ordered fluids, inserted a Foley catheter, and administered premedication: paracetamol 1 g orally.
On day 1 of hospitalisation, a laparotomy was performed under general anaesthesia and epidural. The left adnexa with a 15-18 cm tumour, the uterus with the right adnexa, the web with the gastrocervical ligament, and the pelvic, periaortic, iliac, and obturator lymph nodes were removed. The results of an ad hoc histopathological examination were obtained: adenocarcinoma, most likely clear cell carcinoma of the ovary. A Redon abdominal drain and an intragastric probe were placed. The patient was transported to the intensive care room. The parameters of her general condition were monitored constantly with the use of a cardiomonitor – the values of vital parameters were in the physiological norm. The Foley catheter was used to drain urine; in the collection bag, the urine was clear. The postoperative wound healed normally. Pain was assessed on the NRS scale, and analgesic prophylaxis was administered with positive results.
On postoperative day 1, a postoperative wound toilet was performed; the wound was without inflammatory changes. The intragastric probe was removed in accordance with the doctor’s decision. Pain therapy had mediocre effect. The midwife plays an important role in patient care in the context of pain control, assessing the effectiveness of pain therapy and deciding how to adjust the treatment plan if analgesia is inadequate.
On the second postoperative day, the epidural catheter and Foley catheter were removed. The wound was healing properly, and the patient was urinating independently.
On the third day after the procedure, abundant leakage of serous contents around the drain was observed; for this reason the Redon drain was removed. Since 17:30, the patient periodically vomited and reported spasmodic pain and positive peritoneal symptoms. The postoperative wound was slightly reddened with purulent discharge; a wound culture was taken. At around 20:00, the patient reported persistent severe vomiting; a prescribed medication was administered. Due to unremitting symptoms, a CT scan was performed at around 21:30. The examination showed features of low small bowel obstruction. The patient was transported to the intensive care room. A Foley catheter was inserted. The patient was hydrated, and antibiotic therapy was started.
On the fourth day after surgery at 02:30, the patient reported severe vomiting and nausea, and the doctor inserted an intragastric probe. The patient was sore because of this, and was poorly mobilised.
On the fifth day after the operation, the patient was in a fairly good condition; by the doctor’s decision, the intragastric probe was removed. The patient was mobilised, and the Foley catheter was removed.
On the sixth day after surgery, the postoperative wound was toileted, and the wound reddened slightly. The patient urinated independently. Pain management therapy showed positive results, and antibiotic therapy was maintained. During hospitalisation, the midwife played an important role in monitoring the patient’s condition after surgery, especially during the first few days. She took regular measurements of vital signs, ensured that the patient was properly hydrated, and provided comfortable conditions during the healing process of the surgical wound.
On day 7 after surgery, the patient was discharged home in good general condition with recommendations for further nursing and nutritional management, with particular attention to the evaluation of her obstetric condition. Attention was paid to symptoms of postoperative wound infection such as redness, warming of the operated area, increased wound exudate, and increased pain. Educated on post-operative wound care at home, the patient was requested to follow an easily digestible, protein-rich diet and to stay well hydrated. In addition, the patient was asked to lead a sparing lifestyle. The midwife at the time of discharge played a key role in giving instructions for further home care, monitoring for possible complications, and adjusting the treatment plan if necessary. The patient was advised to contact the family’s community midwife for suture removal, wound assessment, and continued care by the community midwife to follow up on the patient’s condition.
The final diagnosis based on histopathologic findings was as follows: low-differentiated clear cell adenocarcinoma (80%) with focal mucinous endometroid adenocarcinoma (20%). In addition, there were foci of endometriosis in the cervical mucosa, endometrium, right parenchyma, bladder peritoneum, right ovary, and uterine fibroid.

CARE PLAN

Assessments were made on the basis of scales according to the C-HOBIC project, allowing for the evaluation of variables related to basic activities of daily living (Table 1), pain (Table 2), and nausea (Table 3). Based on observations and interviews, a nursing process was created based on the ICNP classification.
The assessment of basic vitals created 2 diagnoses:
Diagnosis 1 – Impaired mobility [10001219].
Interventions (IC):
• Arranging transport of device [10030493],
• Assisting [10002850],
• Advancing mobility [10036452].
Outcome: Impaired mobility [10001219].

Diagnosis 2 – Impaired ability to transfer [10001005].
Interventions (IC):
• Teaching about mobilising device [10037474],
• Arranging transport of device [10030493],
• Assisting [10002850].
Outcome: No transfer injury [10033659].
The pain assessment returned one negative diagnosis, requiring the preparation of a care plan:
Diagnosis 3 – Pain [10023130+2], L: Abdomen [10000023].
Interventions (IC):
• Administering pain medication [10023084],
• Monitoring pain [10038929],
• Nurse controlled analgesia [10039798],
• Assessing pain [10026119],
• Care planning [10035915],
Outcome: Reduced pain [10027917].
The assessment of nausea led to one negative diagnosis, requiring the preparation of a care plan:
Diagnosis 4 – Nausea [10000859+4].
Interventions (IC):
• Assessing nausea [10043694],
• Teaching about managing nausea [10043687],
• Managing nausea [10043673],
• Encouraging rest [10041415],
• Applying safety device [10002472],
• Positioning patient [10014761].
Outcome: No nausea [10028984].

Other diagnoses:
Diagnosis 5 – Vomiting [10025981].
Interventions (IC):
• Managing vomiting [10046329],
• Positioning patient [10014761],
• Assisting with toileting [10023531],
• Providing privacy [10026399],
• Administering intravenous medication [10045836],
• Monitoring fluid balance [10040852],
• Gastric tube care [10046145].
Outcome: No vomiting [10029181].

Diagnosis 6 – Surgical wound [10019265], O: Risk of infection [10015133].
Interventions (IC):
• Evaluating wound healing [10007218],
• Administering medication and solution [10001804],
• Identifying risk of haemorrhaging [10009696],
• Dressing [10006253],
• Contamination prevention [10005055].
Outcome: No infection [10028945].

Diagnosis 7 – Social isolation [10001647].
Interventions (IC):
• Assessing anxiety [10041745],
• Teaching about hospitalisation [10042480],
• Providing emotional support [10027051],
• Managing anxiety [10031711].
Outcome: Reduced anxiety [10027858].

Diagnosis 8 – Dehydration [10041882].
Interventions (IC):
• Assessing fluid intake [10044176],
• Monitoring fluid intake [10035303],
• Monitoring fluid balance [10040852],
• Collaborating in fluid therapy [10030948],
• Fluid therapy [10039330],
• Managing dehydration [10043821].
Outcome: Fluid balance within normal limits [10033721].

Diagnosis 9 – Risk of infection [10015263], Urological catheter [10020373] L: Urethral route [10020341].
Interventions (IC):
• Urinary catheter care [10033277],
• Monitoring signs and symptoms of infection [10012203],
• Assessing exposure to contagion [10044013],
• Teaching about urinary catheter care [10045257].
Outcome: No infection [10028945].

SUMMARY

Ovarian cancer is a dangerous disease that caused more than 200,000 deaths worldwide in 2020 [26]. Treatment is a long and aggravating process that can result in deterioration of patients’ mental and physical state. The diagnosis, made most often at an advanced stage, causes fear for health and life. The care of a midwife plays an important role during the therapeutic process of the client – caring about the patient’s well-being, showing a great deal of empathy, and being able to alleviate physical suffering. Education of the patient is an integral part of the midwife’s work, and it is the basis of communication to be able to understand the problems the patient is facing and quickly intervene to improve their well-being. Adequate care by the midwife helps to reduce anxiety about hospitalisation and the actions taken by medical personnel. The most important tasks of a midwife in postoperative care are as follows: monitoring vital signs, assessing pain and minimising it, observing the wound healing process, helping the patient recover from surgery as quickly as possible, administering medications according to the doctor’s order sheet, providing psychological comfort to the patient, postoperative education, and minimising the risk of postoperative complications. The midwife should update their knowledge based on the latest scientific articles so that postoperative care is in line with current knowledge and ensures the patient’s speedy recovery. The care plan effectively increases the patient’s knowledge of the diagnosis, treatment, and possible postoperative complications. The nursing process, based on the ICNP^® method, addresses a range of problems that a patient may have. All actions of the midwife are aimed at improving the patient’s condition and helping them cope with their new life situation.

Disclosures

This research received no external funding.
The study was approved by the Independent Bioethics Committee for Research at the Medical University of Gdansk (Approval No. KB/650/2023).
The authors declare no conflict of interest.

References