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MELE
Setting:
You are a district nurse who has been involved with Mele’s daughter, Siu and her
children.
This came about whilst you were caring for Mele’s granddaughter, Fai who has
Rheumatic Fever.
Siu’s oldest daughter, Maggie has brought home a slip for permission to have the
Gardasil vaccination. Siu does not know what Gardisal is.When you visit to give Fai
her injection, Siu asks you “what is Gardisal and is this a good thing?”
Action point
Outline the information that Siu needs to know to be able to make an informed
decision.
Free Immunisation
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Immunisation is free for girls aged 9 up to those born on or after 1 January 1990.
All girls aged 9 up to those born on or after 1 January 1990 will be offered free
immunisation through a doctor, medical clinic or a school based programme.
GARDASIL
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Gardasil helps to protect against the types of HPV that cause the majority of cervical
cancer and genital warts. GARDASIL has been clinically tested to be 99-100%
effective in preventing cervical cancer, pre-cancers and genital warts caused by the
four HPV types in the vaccine.
GARDASIL works by causing the body to produce its own protection (antibodies)
against HPV. GARDASIL protects against 70% of cervical cancers1 and 90% of
genital warts.2 You can not get a HPV infection or develop HPV related disease from
GARDASIL.
GARDASIL is indicated for girls and women 9 - 45 years.
GARDASIL is given to you through a series of three shots in the upper arm over a
six-month period.It is very important that you get all 3 shots to get the full protection
from the immunisation.
GARDASIL has been tested on over 20,000 women world-wide, including New
Zealand, and was well tolerated.
The most common patient complaints are skin reactions to the injection: soreness,
redness, swelling and in some cases fever. For the most part these reactions have been
mild. They usually improve or disappear within a few days.
You cannot develop an HPV infection or HPV related disease from GARDASIL
because the vaccine does not contain the complete virus.
GARDASIL is a prescription medicine, and can be administered by either your doctor
or nurse.
GARDASIL is free for girls aged 9 up to those born on or after 1 January 1990.
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If you are not eligible for free immunisation but would like the vaccine you can get it
through your doctor and you will need to pay approximately $165 per dose for each of
the three shots, plus administration and medical fees. The price does vary from doctor
to doctor.
Human Papillomavirus (HPV)
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HPV is a common virus. Most people will become infected with HPV in their
lifetime.
It is not known how much condoms protect against HPV. The HPV virus lives in
certain areas of the skin that aren't always protected by condoms, so even if you are
careful you can still catch the virus.
Women who have one or more types of HPV will still be protected against the HPV
types they have not yet been exposed to that are in GARDASIL. Talk to your doctor
or nurse for more information.
HPV clears up on its own and the cervix cells go back to normal. But for some
women, HPV does not go away and the cervix cells continue to change. This can lead
to serious problems like high-grade abnormalities and cervical cancer.
GARDASIL works best when given before a person has become infected with certain
types of HPV, but may also be of benefit if you or your daughter, have had a previous
HPV infection.
GARDASIL can be helpful in preventing any future HPV infections even if you have
already had an abnormal cervical smear test result. Talk to your doctor or nurse for
more information.
For most women, HPV infection clears up on its own. However, for some women
infected with HPV, the virus can result in the development of abnormalities and
precancerous cells. Cervical abnormalities can be detected by a cervical smear test.
Certain types of HPV, the ones that cause cervical cancer, are also referred to as "high
risk" types.
Cervical Cancer
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What is cervical cancer?
Cervical cancer is a serious condition that can affect women of all ages. Cervical
cancer is the cancer of the cervix, the lower part of the uterus that connects to the
vagina. Cervical cancer develops when abnormal cells in the cervix lining multiply
following a viral infection.
GARDASIL helps prevent cervical cancer by immunising against the types of HPV
that cause most cervical cancers. To prevent cervical cancer caused by other types of
HPV, women must also have regular pap tests.
These screening tests detect early cell changes in the cervix (called ‘precancers'), so
that if required, they can be treated before the changes become cancerous.
Action point
Discuss the aetiology of cervical cancer
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Cervical cancer is cancer of the cervix, which is the lower part of the uterus or womb.
Cervical cancer develops slowly over time, usually taking many years, when
abnormal cells grow on the cervix.
These abnormal cells are caused by infection with high-risk types of HPV.
Abnormalities in the cells of the cervix can be detected by cervical screening and
removed.
Each year there are around 25,000 abnormal smear test results among New Zealand
women.
Without cervical screening about one out of 90 women will develop cervical cancer
and one out of 200 will die from it. With screening about one out of 570 will develop
cervical cancer and one out of 1,280 will die from it.
Regular three-yearly cervical smear tests are recommended for all women aged 20 to
70 who have ever been sexually active.
There are two main types of cervical cancer. Squamous cell carcinoma, the most common
type of cervical cancer, starts in the squamous or skin-like cells, which cover the outer
surface of the cervix at the top of the vagina. Adenocarcinoma is a less common type of
cervical cancer. It starts in the glandular cells, in the cervical canal. Cervical cancer may be
microinvasive or invasive.
Microinvasive cervical cancer: This is when cancer cells have just broken through the
bottom layer of the skin of the cervix.
Invasive cervical cancer: Cancer cells have spread from the surface skin of the cervix into
the deeper tissues of the cervix. The cancer may also have spread to part of the vagina, lymph
nodes or other tissues.
How common is cervical cancer?
In New Zealand, about 150 women are diagnosed with cervical cancer each year.
Signs and symptoms of cervical cancer
Early changes in the cells of the cervix don’t usually cause symptoms, which is why doctors
encourage women to have regular cervical smear tests.
If early cell changes develop into cervical cancer, the most common signs include:
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vaginal bleeding between periods
bleeding after intercourse
pain during intercourse
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unusual vaginal discharge
vaginal bleeding after menopause
excessive tiredness
leg pain or swelling
low back pain.
All these symptoms are common to many conditions and may not mean you have cervical
cancer. However, if you have these symptoms, have them checked by your doctor.
Causes of cervical cancer
Some factors seem to put some women at a higher risk of cervical cancer. These risk factors
include:
• Human Papilloma Virus (HPV).
Almost everyone is infected with HPV at some stage in their life. Most cases of HPV resolve
(improve) without treatment and have no ill effects. Most women who have HPV do not ever
show signs of abnormal cell changes. However, in some women it can cause cell changes that
lead to dysplasia. If untreated, they may become cancer.
A vaccine has now been developed that prevents the types of HPV most commonly linked to
cervical cancer. The vaccine is most beneficial if given to young girls before they are exposed
to HPV, that is, before they start having sex.
• daughters of women who used the drug diethylstilboestrol (DES) during pregnancy to
prevent a miscarriage. The use of this drug has declined since the 1940s and 1950s.
• smoking.
How long does it take for cervical cancer to develop?
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Cervical cancer can develop over 10 or more years.
Women receiving normal cervical smear test results can already be infected
with HPV.
A small proportion of women infected with HPV whose immune systems are
not clearing the infection are at risk of developing precancerous
abnormalities. If these are not detected through cervical screening and
treated, they can lead to cervical cancer.
Most but not all women with high-grade abnormalities on the cervix will
develop cervical cancer if they are not treated.
There can be a long interval between being infected with HPV, the
development of abnormalities and the development of cancer
Action point
Discuss the issue of informed decision making and the rights of children.
Youth Participation is a right
NZ became past of the United Nations Convention on the Rights of the Child (UNCROC) in
1993. UNCROC states that all young people under 18 years of age have the right to
participate in decision making.
Human Rights NZ 2010 outlines that:
 Children and young people have the same basic general human rights as adults
 Have specific human rights that recognise their special need for protection
http://www.hrc.co.nz/repor/chapters/chapter04/children01.html#wha
http://www.myd.govt.nz/working-with-young-people/youth-participation-in-decision-making/index.html
Action point:
Identify all the immunisations on the free schedule and eligibility criteria.
HPV immunisation programme – New Zealand (2008) – Gardasil
Female- age 12 years- school(year 8)
 From 2011 onwards, the Gardasil vaccine is offered to girls 12 years of age.
 The vaccine can be obtained through available health centres and GP’s.
 Given as a course of three injections over a six month period
Females aged 12-20 years
 commence before 20th birthday
Females born in 1990 or 1991
 Have until 31 December 2011 to start the course
Setting:
The two oldest girls are starting to rebel against their mother’s restrictions on their social
activities. Part of Siu’s concerns around the vaccinations for HPV centres around the church
telling them it is a bad thing because it will make the girls more sexually active.
Action point
How can you help Siu with this problem? What help can she find in the community?
Inform Siu that there are available non government agencies which provide information more
information on the programme. These are:
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Family Life Education Pasefika(FLEP)
Affirming Women
Te Rapakau Health
Waikato Pacific Island Health Community
Action point
If one of the girls did get pregnant, outline her legal rights, citing relevant legislation in
detail.
If you are undecided about what to do, remember you do have choices 
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You can keep your baby and bring up your baby yourself, hopefully with some great
support from friends and family
You can continue with your pregnancy and then have your baby adopted by another
family
You can continue with your pregnancy, but have your baby brought up by another
family member.
You may decide to terminate your pregnancy (have an abortion). In New Zealand this is
legal at any age, with or without your parents’ consent, so long as 2 doctors agree that
continuing with your pregnancy would be a danger to your physical or mental health.
You are entitled to see another doctor if your own doctor does not agree with abortion.
Setting:
There is considerable discussion about the fact that the two teenagers in the family have
become very conscious of their weight and want to conform to the peer accepted slim image.
Mele and her daughter express that this is not ok because then their friends would accuse
them of not feeding the children properly. They add that it is their way to be large.
Action point
How will you respond to these statements?
One of the most important elements in Pacific people is their culture. Culture includes how
they understand their sickness. Therefore it is vital to treat the client holistically. As nurses
we need to learn about Pacific physical needs, for example learning about what is their diet,
cultural food and its significance. Education and advice them on the effects of illness cause
by healthy eating, ask and dialogue with the patient on the cause of obesity. From a pacific
perspective, obese means that you are well fed and well nurture and from the westernised
culture it is unhealthy. Therefore, having the knowledge about pacific people’s practises and
beliefs will help them to integrate this into planning their cares.
Action Point:
BMI is usually used to determine if people are overweight or obese. Identify the drawbacks
of this system based on ethnic variations.
Are you able to identify any other measurements of healthy weight? If so, what are they?
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Body Fat Testing
Target Heart Rate
Blood Test
Waist Circumference
Waist to Hip Ratio
Action point
Identify members within their own community who may help the family with this problem.
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Family members
Nurses of the same ethnicity, gender- assist in case of language barrier
Church members
Pacific women’s group
Action point
Discuss the effects migration has had on the health of Pacific peoples.
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Culture
Language and education
Cost
Past experiences
Cultural Safety
Setting:
Mele, who is Agnes’s friend and companion, has been persuaded to go to her GP. Agnes and
Mele’s daughter have noticed that she has a very nasty smell, even after a shower and is
losing weight. The GP finds that Mele has a suppurating mass on her Left Breast. This is
strongly indicative of advanced carcinoma. Mele is admitted to hospital but after family
conference with the oncologist she is returned home.
Action point:
Describe the more common types of breast cancer, also identifying when there is a genetic
factor.
Carcinoma in situ (in SIGH-to): This term is used to describe the early stage of cancer,
when it is confined to the place where it originated, typically the ducts or the lobules. It has
not yet spread into the fatty tissues in the breast or to other organs in the body.
Ductal carcinoma in situ (DCIS): This is the most common type of noninvasive breast
cancer and almost all women at this stage can be cured with treatment. DCIS means that the
cancer is confined to the ducts and has not spread through the walls into the fatty tissue of the
breast. A mammogram is the best way to detect DCIS in its early stage.
Lobular carcinoma in situ (LCIS): This is not a true type of cancer; however, having LCIS
increases a woman's risk of getting cancer later. It originates in the milk-producing glands but
does not go through the wall of the lobules. It is very important that women with LCIS
frequently check for signs of breast cancer and follow screening guidelines.
Infiltrating (invasive) ductal carcinoma (IDC): This is the most common type of breast
cancer. It originates in a milk passage or duct, spreads through the wall of the duct, and
invades the fatty tissue of the breast. From there it can spread to other parts of the body. IDC
accounts for about 80% of invasive breast cancers.
Infiltrating (invasive) lobular carcinoma (ILC): This type of cancer originates in the milk
glands or lobules. It can then spread to other parts of the body. ILC accounts for about 10%
of invasive breast cancers
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Only about 5 percent of those patients who develop breast cancer, have will have one
or more identifiable genetic risk factor for breast cancer. This means majority of the
breast cancers are unrelated to genetic risk factors. However if a woman inherits a
genetic mutation like BRCA1 and BRCA2 the lifetime risk of development of breast
cancer in that woman may be as high as 85 percent.
BRCA1 and BRCA2 mutations may also be associated with increased risk of
development of breast cancer at younger age, hence when a young woman develops
breast cancer this possibility should be explored especially with other family members
affected with breast or ovarian cancer.
Both BRCA1 and BRCA2 are inherited as autosomal dominant mode and can be
passed to offspring by either paternal or maternal lineage.
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In the general population the incidence of BRCA1 mutation is between 1 in 500 and 1
in 800. The incidence of BRCA2 mutation is even lower. BRCA1 and BRCA2 are not
the only genetic abnormalities that increase risk of breast cancer. Mutations in several
other genes have been associated with hereditary breast. These mutations account for
only a minor fraction of hereditary breast cancers. The great majority of hereditary
breast cancer occurs in carriers of BRCA1 and BRCA2. Overall, it has been estimated
that inherited BRCA1 and BRCA2 mutations account for 5 to 10 percent of the total
breast cancers.
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BRCA2 gene is located on chromosome 13. The risk of development of breast cancer
in women carrying BRCA2 mutations are BRCA2 gene is located on chromosome 13.
The risk of development of breast cancer in women carrying BRCA2 mutations are
similar to the risk of BRCA1 carriers, however the risk of development of ovarian
cancer is lower in BRCA2 mutation carriers compared to BRCA1 mutation carriers.
Men carrying BRCA2 mutation have an increased risk of developing breast cancer
and the lifetime risk for a male carrier is about 5 percent. Breast cancer in a male is
rare, but when it occurs it may be associated with BRCA2 mutation. BRCA2
mutations may also increase risk of other cancer including pancreatic cancer, stomach
cancer, gallbladder and bile duct cancer, and melanoma.
Action point:
Differentiate between benign and malignant growths
Differentiation
Nuclear Fission
Benign
Small shaped,similar shape
to original form
None or Few
Malignant
Large shaped, different shape
to original form
More common and can be
seen as pathological nuclear
fission
Fast
Invasive growth and
exogenous, which no
envelope, and the general
surrounding tissue is not
clear boundaries, usually can
not promote, with the latter
every invasive growth
Growth Rate
Growth Mode
Slow
expansion of exogenous
growth, which often form
coated with clear boundaries
around the organization in
general, it can often push
Secondary changes
Necrosis, bleeding
Frequent bleeding, necrosis,
such as the formation of
ulcers
Movement
Recurrence
Does not transfer
Few post-operative relapse
Often transfer
After the surgery, such as the
treatment of relapsed more
Benign Growth
Benign tumors are slow growing lesions which remain localized to the site of origin. This
means that it does not spread into adjacent tissue. A benign tumor is NOT cancer. There are
different types of benign tumors that are named according to the site where it occurs.
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Epithelial tumors are either papillomas (arising from non-secretory epithelium) or
adenomas (arising from secretory epithelium).
Mesenchymal and connective tissue tumors are usually named according to the tissue
of origin and appended with the suffix ‘oma’. For example lipoma is a benign tumor
arising from fat cells of lipid tissue or osteoma from bone tissue. However, there are
several exceptions like lymphoma, myeloma which are malignant tumors or
tuberculoma which is a lesion in tuberculosis.
Characteristics of a Benign Tumor
These are slow growing tumors made up of cells that closely resemble the parent cells of the
organ or tissue of origin. The benign tumors do not spread to surrounding tissue or to distant
sites in the body. The nucleus of the benign tumor cells remains normal and the border of the
tumor is well defined or sometimes encapsulated. Some long standing benign tumors may
turn malignant eventually.
Effects of Benign Tumors
Even though benign tumors are confined to its site of origin, it can lead to certain clinical
complications.
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It can cause pressure effects on the adjacent tissues. For example, a benign tumor of
the pituitary gland can cause visual disturbances by compressing the optic nerve.
A benign tumor can secrete hormones. For example, a benign tumor of the thyroid
gland can cause thyrotoxicosis (excess of thyroid hormones) or a gastrinoma
(stomach) can secrete gastrin leading to high gastric acid production.
Sometimes a benign tumors can transform into malignant tumor (cancer). For
example, adenomatous polyps of the colon can progress to adenocarcinoma of colon
(colon carcinoma).
Benign tumors can physically impede the normal functioning of certain organs. For
example, a large lipoma near a joint can interfere with full mobility of the joint while
a large fibroid of uterus may interfere with normal labor.
Benign tumors can cause some psychological impact – depression due to cosmetic
reasons or anxiety because of fear about the tumor turning dangerous.
Malignant (Cancerous) Growth
Malignant tumors are lesions with uncontrolled growth that invades surrounding tissues and
spreads to distant sites. The pattern of growth and invasion is the reason that a malignant
tumor or malignancy is known as cancer.
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Malignant epithelial tumors are called carcinomas like squamous cell carcinoma or
adenocarcinoma.
Malignant tumors of connective tissue are called sarcomas like liposarcoma,
fibrosarcoma or osteosarcoma.
Malignancy of the blood is called leukemia and that of lymphoid tissue is known as a
lymphoma.
Some tumors do not fall into either of the classical groups and are often referred to as
borderline tumors.
Characteristics of Cancer
Malignant tumors are fast growing lesions. The cells resemblance of the parent cells of the
organ or tissue of origin is highly variable and often the resemblance is poor. It divides
rapidly. The malignant cells have hyperchromatic nucleus with an irregular outline, multiple
nucleoli and are pleomorphic. It can invade the surrounding tissue and spread to distant sites
(metastases). The border of the malignant tumor is poorly defined or irregular. There may be
necrosis or ulceration in the malignant tissue.
Effects of Cancer
Malignant tumors are extremely harmful, cause significant damage and often leads to death if
left untreated.
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A malignant tumor can compress the adjacent tissue and directly invade the area.
It may spread to distant sites and form secondary tumors (metastases).
Some cancer can lead to hemorrhage and subsequent blood loss from ulcerated
surfaces like colon cancer.
Tumors of hollow organs can lead to obstruction of the lumen and affect the
movement of substances through these cavities. For example, a malignant tumor of
esophagus, stomach or colon can cause obstruction to passage of food and feces.
Some malignant tumors also produce hormones like ACTH from certain lung tumors.
Cancers usually cause weight loss and debility (cancer cachexia)
Cancers are often associated with severe pain in late stages.
Malignant tumors tend to cause serious psychological trauma, particularly associated
with fear and depression of impending death and recurrence
Action point:
Identify the three main treatment therapies for neoplasia.
The specific treatment of a cancer depends on the type of cancer, its location in the body and
how far throughout the body it has spread. There are three main cancer treatments that can
help stop or slow the spread of cancer.
In chemotherapy, a combination of drugs is used in order to combat the cancer. The drugs
used depend on the type of cancer that the patient has. They are sometimes used to shrink
tumors so that a doctor can surgically remove them.
The drugs in chemotherapy are usually given orally, but they may also be injected. After each
chemotherapy session, patients are left to rest for around one week to a month. The drugs can
cause some side effects, including hair loss, sickness and mouth sores. Chemotherapy usually
lasts a maximum of six sessions.
Radiotherapy, another of the three major cancer treatments, attempts to kill the cancer cells
with radiation. The radiation is administered by controlled x-rays to the cancer-affected area.
The x-rays are administered in a specific way in order not to cause damage to the surrounding
tissue. Like all cancer treatments, radiotherapy can cause some side effects, such as
depression, lethargy and a lack of appetite. Some women who have radiotherapy in the pelvic
region have been known to start menopause early.
The last of the major cancer treatments is invasive surgery. If cancer is still in the early stages
and has not spread, then surgery is sometimes the best treatment. Surgery is also used if the
cancer appears as solid tumors. Some of the surrounding tissue, including some lymph nodes,
may also be removed during surgery in order to prevent the cancer from returning.
In addition to the three major cancer treatments, a combination of cancer treatments may be
advised by an oncologist, a doctor who is trained specifically to diagnose and treat cancer. A
combination of the cancer treatments discussed above is known as a multi-modality
procedure.
If the disease has spread too far for any treatment to be effective, then palliative care will be
given to improve the quality of life for the sufferer. Palliative care aims to relieve pain during
the remaining lifetime of the sufferer. Cancer treatments are under constant research, and vast
amounts of funds and manpower are used to find new cancer treatments every year.
Setting:
Mele has never had breast screening because she says she didn’t really understand what it
did and whether it was painful. She also said she was too shy and embarrassed.
Action point:
Identify government and non-government initiatives in place to address these issues within
the pacific community.
Breast Screen Aotearoa
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provide free mammograms to women age 45-69
National Screening Unit
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campaign targeting Pacific women and their communities
aims to raise awareness about breast screening and increase understanding of the
benefits of early detection
New Zealand Breast Cancer Foundation
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Non profit organisation and non government funded charitable trust
Provide free nationwide breast health and cancer seminars
Education resources