Outcome
Ms Y’s most recent Pap test result, performed 7 months after the LEEP, was normal and negative for HPV. Her next follow-up for cervical cancer screening with the Pap test was scheduled for November 2016, a year after her last Pap test.
Discussion
Practitioners who provide healthcare services to women should be knowledgeable about the Pap test and follow-up of abnormal results. Unfortunately, there are misconceptions and a lack of knowledge among patients about the follow-up of abnormal Pap test results. Ms Y kept all of her appointments, yet she reported, “I felt uneasy about the whole thing.… I felt as though I did not know enough about what was going on.” Ms Y thought the Pap test was used “to check for diseases” and “I did not know that there were guidelines to follow.”
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The following sections will discuss current evidence-based guidelines regarding cervical cancer screening, cervical cancer vaccines, and the follow-up of abnormal Pap test results.
Cervical cancer screening. Cervical cancer screening with the Pap test is only effective if precancerous lesions are treated before they progress to cervical cancer.1 Prior to 2012, the consensus was that providers should perform an initial Pap test in women who are 18 years old or at least 3 years after their first sexual experience.2, 3 The guidelines were subsequently changed, and the current recommendation is that cervical cancer screening with the Pap test alone should begin at 21 years of age and continue to 29 years of age. 1, 4, 5 Women who are aged 30 and older (up to 65 years of age) should obtain a Pap test along with HPV testing. 1, 4, 5 Generally, HPV testing should not occur in women who are younger since HPV is prevalent among them and they tend to clear the virus before it causes changes to the cervix and cervical cancer. Aggressive treatment of HPV-positive results in women younger than age 30 is avoided, as is subsequent cervical insufficiency and the delivery of preterm babies.5
Cervical cancer vaccine. Gardasil 9 is the most recent HPV vaccine that prevents disease associated with HPV.6 It is a 9-valent vaccine that prevents genital warts due to HPV types 6 and 11 and cervical, vulvar, vaginal, and anal cancers due to HPV types 16, 18, 31, 33, 45, 52, and 58. Gardasil 9 was approved by the FDA for females aged 9 to 26 years and males aged 9 to 15 years.6 The recommended age for routine vaccination is 11 and 12, and providers can make the decision if the vaccine is appropriate at the ages of 9 and 10. 6, 7 Gardasil 9 is given in 3 intramuscular doses; the first dose is administered during the recommended age.6 The second dose is given 1 to 2 months after the first dose, and the third and final dose is given 6 months after the first dose.6 Recently, after reviewing numerous studies, the CDC approved a 2-dose vaccine regimen for preteens who are 11 to 12 years of age. 8 It was found that a 2-dose vaccine regimen produced the same or higher immune response as a 3-dose vaccine. 8 The most common adverse effects are pain, swelling, and redness at the injection site, as well as headaches.6
Abnormal Pap test results. The American Society for Colposcopy and Cervical Pathology (ASCCP) (2014) provides evidence-based guidelines for the management of abnormal Pap test results.7 Recommendation for the follow-up of abnormal Pap test (cytology) results differs according to the results of HPV and cytology testing. For example, HPV and cytology (co-testing) screening for women aged 30 and older is recommended every 5 years.4, 7 Additional information can be obtained from the organizational resources that are shown in Table 2.
Table 2. Organizational resources
| Organizations | Resources |
| ACOG | http://www.acog.org/Patients/FAQs/Cervical-Cancer-Screening |
| ASCCP Website | www.asccp.org/ |
| ASCCP Guidelines | http://www.asccp.org/asccp-guidelines |
| ASCCP mobile app | http://www.asccp.org/store-detail2/asccp-mobile-app |
Conclusion
Ms. Y’s most recent treatment plan was accurate according to the ASCCP guidelines, but one important step was missed in her previous treatment. She could have received the HPV vaccination at age 23, regardless of her diagnosis of HPV.
Advancements in technology and medicine have made it easier for practitioners to stay current with the most up-to-date guidelines and recommendations for abnormal Pap tests and HPV diagnosis. The ASCCP developed a mobile app for providers to have the most current guidelines at their fingertips. The app is user friendly and has the updated consensus guidelines for managing abnormal Pap test results and cancer precursors. Recommendations and algorithms can be viewed following client data entry with a few simple keystrokes. The newest HPV vaccination, Gardasil 9, is on the market and helps prevent cervical cancer. Guidelines, technology, and advanced medicine make it possible for practitioners to provide quality care to clients such as Ms Y.
Denise Linton, DNS, FNP-BC, is an associate professor and nurse practitioner coordinator and Rachel Ellison, PhD, is an assistant professor at the University of Louisiana at Lafayette, College of Nursing and Allied Health Professions.
References
- American Cancer Society. Cancer facts & figures 2016. Available at: http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf
- American Cancer Society. Cancer facts & figures 2009. Available at:www.cancer.org/acs/groups/content/@nho/documents/document/500809webpdf.pdf
- US Preventive Services Task Force. 2014. The guide to clinical preventive services: Screening for cervical cancer. Publication No. 06-0588. Available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2a.html#Cervical
- Cervical cancer screening. The American Congress of Obstetricians and Gynecologists. Available at: http://www.acog.org/Patients/FAQs/Cervical-Cancer-Screening
- US Preventive Services Task Force. Final recommendation statement: cervical cancer: screening. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening
- FDA. FDA approves Gardasil 9 for prevention of certain cancers caused by five additional types of HPV. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm426485.htm
- American Society for Colposcopy and Cervical Pathology. Algorithms: Updated consensus guidelines for managing abnormal cervical cancer screening tests and cancer precursors. Available at: http://www.asccp.org/asccp-guidelines
- CDC Newsroom. CDC recommends only two HPV shots for younger adolescents. Available at: https://www.cdc.gov/media/releases/2016/p1020-hpv-shots.html
