Resources

  1. Curry, J. (2018). Screening for cervical cancer: US Preventive Services Task Force Recommendation Statement. JAMA.320(7):674-686. doi:10.1001/jama.2018.10897 https://www.ncbi.nlm.nih.gov/pubmed/30140884
  2. https://jamanetwork.com/journals/jama/fullarticle/2697704
  3. Centers for Disease Control; Human Papilloma Virus (HPV) materials for parents, providers and organizations: https://www.cdc.gov/hpv/index.html




Transcript

Dr. Frank Domino:

Diana is new to your practice and here to have an annual exam. She is a 58-year-old African-American female who recently moved to the area and has a new job with new health insurance. It has been five years since she's had an annual exam. She described herself as mostly healthy but she has recently used Urgent Care twice in the last five years. Once for pneumonia and the other for an ankle sprain. She is wondering what she needs for today's visit as she's been a bit neglectful of her health in recent years.

Hi, this is Frank Domino, and joining me today is Jill Terrien Associate Professor and Director of the Nurse Practitioner Specialties Program at the University of Massachusetts Medical School's Graduate School of Nursing. Thanks for coming today, Jill.

Jill Terrien:

Thank you for having me, Frank.

Dr. Domino:

So, Diana sounds like a wonderful patient. She's new to our practice, she sounds for the most part, relatively healthy, but she hasn't had any sort of annual exam in over five years. What diseases do we need to think about screening for her today?

Jill Terrien:

So for today, really, the goal is to establish her care with you as the provider and look at her risk factors for her family history. But really screening... Consider screening for breast cancer, colon cancer, doing a cardiovascular look at her as well. And then of course the look at Gyn exam, 'cause she hasn't had cervical cancer screening in at least five years and we need to know how long.

Dr. Domino:

So Jill remind us if you would please, about the old guidelines for cervical cancer screening.

Jill Terrien:

So for women aged 21-30, the old guidelines were to do cervical cytology, which some people call Pap with a reflex HPV testing, and those, for over 30 or between 30 and 65 it was the Pap test and the HPV check every three to five years. So, that's what preceded these guidelines. So now, for in Diana's time or talking about the new guidelines, it is for women aged 21-29, is gonna be cervical cytology or Pap alone in women and that's an A recommendation. In women 30-65, you have options. You have cervical cytology alone every three years or every five years you do HPV testing alone or you put the two tests together which is called "co-testing". So you do a Pap and an HPV every five years, and that's really what we're gonna be talking about with Diana and that's the change. And then for women over 65, it's really has not really changed unless they have other risk factors.

Dr. Domino:

What might be risk factors over 65 that would make you do something differently?

Jill Terrien:

So if they're over 65 and they have a new partner that would be something to consider and that would be taken on a case by-case basis.

Dr. Domino:

Okay. If they're immuno-suppressed or they've had a history of abnormal Paps in the past it seems like you might... Or a highly suspicious HPV subtype that would probably also make you be a tiny bit more aggressive but that's fairly uncommon, hopefully in our 65 and olders.

Jill Terrien:

And then, just for our general population, things to consider as you're having Diana come into your practice are has she had any abnormal results for her Gyn screening in the past? Things like pre-cancerous lesions that were treated, or the fact of was she exposed to DES in utero? Those are people to consider. Also people that are immuno-suppressed need different screening schedule.

Dr. Domino:

What was the rationale around this change? Do you have any idea?

Jill Terrien:

Well, I think it can be a combination of factors. Number one, when we had the 2012 recommendations and it came to light that we didn't need to screen women under 21, that was a big practice change, because if we had sexually active teenagers and we counted partners and then we might screen them earlier. Some people might have had yearly Pap testing. And what we know now is, is that the majority of cervical cancer is caused by the HPV virus and that in women that might be exposed to that, that will clear by the time they're in their late '20s or by 30. So, the evidence also has shown that or demonstrated that HPV vaccination has changed the scene here as well. So all of that and the data they looked at systematic reviews, matter analysis and cohort studies to find out in these different age groups what they were seeing.

Dr. Domino:

I think you're absolutely right. I think the evolution that's happened with regard to both the impact of HPV testing as well as we realize that cytology led to many false positives. We found lots of abnormal cells, lots of HPV induced changes that were gonna get cleared and so it's really the active virus that we're worried about now and these new guidelines are very healthy at reflecting that. You mentioned earlier, that Diana is gonna need some other screening tests, what would you recommend for a 58-year-old female today for breast cancer, colon cancer and cardiovascular risk?

Jill Terrien:

So, the thing is we'd have to look at her breast cancer screening history if it has been... First, we look at her personal history and then her risk factors from her family. And then depending on that she may need to have a mammogram. That might be recommended for her. Also, has she had a colonoscopy at all? And if it's been greater than five years or maybe she's never had a colonoscopy that would be something to consider. And then, of course, her cardiovascular prevention has lab work that would include lipids, what about exercise, checking her BMI and also looking at whether or not we're gonna recommend Low Dose Aspirin to her based on her risk assessment.

Dr. Domino:

So it sounds like Diana is gonna have a busy day today, with all the testing that she'll probably need, but being able to just perform an HPV test, and not worry so much about a Pap. It might make life a little bit easier for everyone. Thanks again, Jill.

Jill Terrien:

Thank you Frank.

Dr. Domino:

Practice pointer: For women of average risk between the ages of 30 and 65 HPV testing every five years is now recommended as screening for cervical cancer. And for more timely relevant and practical medical education, check out pri-med.com.