By Sue Woodson, CNM, MSN
Certified Nurse Midwife at Jefferson Obstetrics & Gynecology, Ltd., Charlottesville, VA
Tips for Clinicians and their Patients
"What do you mean you only want to see me every 3-5 years? I am used to coming EVERY year for my pap smear!"
In the U.S., women generally think having a Pap smear is the main purpose of an annual exam as a way to screen for cervical cancer. This perception is understandable given that as a result of regular Pap screening, the incidence and mortality from cervical cancer in U.S. women has dropped by at least 80% since the 1960s. Today, annual pap smears are rarely performed every year, yet, many women continue to confuse a pelvic exam (physical assessment) with a Pap smear (lab test). To address this misperception women's health nurses must educate women about the screening tests offered during an annual exam and why and when they are recommended.
WHY HAS THIS HAPPENED?
1. Science and technology have improved
Many of us can recall a time when a Pap smear consisted of cervical mucus smeared directly on a microscope slide in the exam room, fixed with hairspray (or other fixative), the slide was boxed in cardboard, labeled, and sent to the lab for evaluation. With such crude technique, is it any wonder that years ago, Pap smears were recommended for all women every 3-12 months? Thankfully, cervical cancer screening techniques and methodology have evolved resulting in greater Pap reliability and sensitivity.
2. We know the cause of cervical cancer and can prevent it
Virtually all cervical cancer is caused by the human papilloma virus (HPV) (National Cancer Institute, 2015). HPV is so prevalent, it can be considered the common cold of the genital tract. We now have the ability to test for this virus and discriminate between high and low risk types. The HPV vaccine prevents the strains most likely to cause cervical cancer and studies have shown the vaccine also prevents women from developing the pre-cancerous lesions which in the not so distant past required damaging procedures to eradicate.
3. Cervical cancer grows slowly
Cervical cancer takes 10-15 years to evolve from a pre-cursor lesion. Fortunately, most pre-cursor lesions never become malignant. We have learned patience in our screening efforts and now understand scenarios when intervention is prudent and when continued observation may be the best course. Screening every 3-5 years affords ample opportunity to intervene before a malignancy can develop in most cases.
TIPS FOR YOUR PATIENTS
The American College of Obstetricians and Gynecologists (ACOG), the United States Preventive Task Force (USPSTF), and the American Cancer Society (ACS) recommend the following guidelines (Saslow et al., 2012; USPSTF, 2012).
Note that these guidelines do NOT apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).
1. Teens don't need a Pap smear
The good news for teens is that women under the age of 21 are NOT recommended to be screened for cervical cancer. Benign changes in the cervix caused by HPV are very common but the great majority resolve on their own and any that don't grow so slowly that screening for cervical cancer is not recommended. Many mothers of teens who recall starting Paps as teens themselves may not realize this was because the cause of cervical cancer was not yet known and we didn't realize that most changes in the cervix caused by HPV would go away without treatment in teens and young women.
2. Women in their 20s need a Pap every 3 years
Women aged 21 to 29 years are advised to have Paps every three years. They aren't recommended to have an HPV test because HPV infections are very common in this age group, especially if a woman hasn't been vaccinated, and as with teens, these infections generally go away on their own.
3. Women ages 30 to 65 years should have a Pap with an HPV test every 5 years
When a woman turns 30 the preferred recommendation is to have a Pap and HPV every 5 years. If both are negative (normal) the chance that cervical cancer would develop in 5 years is very low. Women can also choose to have a Pap alone every 3 years.
4. Paps can stop after age 65
If a woman has no history of cervical pre-cancer or cancer and has had either 3 normal Paps in a row or two normal Paps and HPV tests in the past ten years, with the most recent in the past 5 years, she can stop cervical cancer screening altogether.
5. Skipping Paps puts women at risk
Women at highest risk for cervical cancer are those who have never been, or are rarely, screened. As long as women are regularly screened at the currently recommended intervals, evidence shows that the risk of developing cervical cancer is very low.
6. Annual exams are awesome even if you don't need a Pap
There's a lot more that happens at an annual exam than a Pap test. The annual exam promotes reproductive and overall wellness. Important topics to discuss at an annual exam are a woman's reproductive life plan (when, if and how many children she desires) , contraception, preventive screenings and vaccinations, sexually transmitted infections, sexual health, healthy relationships, mental health, genetic risks, nutrition, healthy weight and activity, and medication and substance use.
7. A vaccine against cancer? Yes, it's true!
The HPV vaccine is recommended for girls (and boys) starting at age 11 so they can be protected against HPV before they are exposed. The vaccine protects against genital warts, cervical cancer, and several other cancers caused by HPV. Young women can receive the vaccine through age 26 and young men through age 21 if they haven't been vaccinated in their teens.
A CERVICAL CANCER-FREE WORLD
We have powerful weapons to fight and, most importantly, prevent cervical cancer, a cancer that was once killed more women than any other cancer. Make sure the women you care for understand how they can best protect themselves and their loved ones so we can move closer to a cervical cancer-free world.
Originally posted on AWHONN Connections
Saslow, D., Solomon, D., Lawson, H. W., Killackey, M., Kulasingam, S. L., Cain, J., ... & Wentzensen, N. (2012). American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA: a cancer journal for clinicians, 62(3), 147-172.