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CERVICAL CANCER SCREENING AND THE COMMUNITY
Screening Capstone Project Paper: Cervical Cancer Screening
Nipa Patel
Concordia University, Nebraska
December 15th, 2014
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CERVICAL CANCER SCREENING AND THE COMMUNITY
Background
Cervical Cancer
The cancer that starts in the cervix is called cervical cancer. The cervix is the lower,
narrow end of the uterus (Center of Disease Control and Prevention, 2014). The cervix
connects the vagina to the upper part of the uterus (Center of Disease Control and
Prevention, 2014).
Studies have found that infection with the virus called the Human Papillomavirus
(HPV) is the cause of almost all cervical cancers (MedicineNet). More than half of women
by the age of 50 have been exposed to HPV, but most HPV infections clear up on its own
(MedicineNet). An HPV infection with a high risk type of HPV that does not go away can
cause cervical cancer (MedicineNet). Other risk factors for cervical cancer include having
many sexual partners, smoking, taking birth control pills, and engaging in early sexual
activities (MedicineNet).
Early cervical cancers usually do not have symptoms. When the cancer grows large,
women may have abnormal vaginal bleeding, increased vaginal discharge, pelvic pain or
pain during intercourse (MedicineNet).
Cervical Cancer Population and Screening Tests
In 2011, Hispanic women had the highest rate of getting cervical cancer, followed
by black, white, America/Indian/Alaska Native, and Asian/Pacific Islander women (Center
of Disease Control and Prevention, 2014). In 2011, black women were more likely to die of
cervical cancer than any other groups, followed by Hispanic, white, Asian/Pacific Islander,
American Indian/Alaska Native women (Center of Disease Control and Prevention, 2014).
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CERVICAL CANCER SCREENING AND THE COMMUNITY
Cervical cancer is highly preventable in most Western countries because screening
tests are available (Center of Disease Control and Prevention, 2014). When cervical cancer
is found early, it is highly treatable with long survival and a good quality of life (Center of
Disease Control and Prevention, 2014). Two screening tests can help prevent or early
detect cervical cancer; the Pap and HPV test. All women between the ages of 21 and 65
years old should get a Pap test (Center of Disease Control and Prevention, 2014). HPV test
is recommended for women over age 30 (National Cervical Cancer Coalition). The Pap test
looks for cell changes on the cervix that might become cervical cancer if not treated (Center
of Disease Control and Prevention, 2014). The HPV test looks for the virus, HPV, which
can cause these cell changes (Center of Disease Control and Prevention, 2014).
Epidemiological Data on Cervical Screening Tests
Women between the ages of 21 and 65 years should be screened for cervical cancer
with a Pap test at least every three years (Center of Disease Control and Prevention, 2014).
The National Interview Survey found screening rates in 2010 for cervical cancer to be 83%
which is below the target 93% (Center of Disease Control and Prevention, 2014). Screening
rates were lower among Asians (75.4%) (Center of Disease Control and Prevention, 2014).
Blacks followed by Hispanics and white had higher rates of screening. The percentage of
cervical cancer screening varies by education level. Women with the higher education are
most likely to have had a Pap test in the last three years (Center of Disease Control and
Prevention, 2014). Next, the percentages of cervical cancer screening vary by age. Women
aged 18 to 44 years are most likely to have had a Pap test in the last three years (Center of
Disease Control and Prevention, 2014). From 2000 to 2010, the rate of women who
reported getting a Pap test within the last three years dropped 3.3% over the 10 year period
(Center of Disease Control and Prevention, 2014).
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CERVICAL CANCER SCREENING AND THE COMMUNITY
Cervical Cancer Screening Tests and Probabilities
Sensitivity is the percentage of “true positive” cases that are detected by the
screening test and specificity is the percentage of “true negative” cases that are negative by
the screening test (National Cancer Institute). Such studies have rarely been done for any
screening test for cervical cancer (National Cancer Institute). Studies that compare Pap test
with repeat Pap test have found the sensitivity of any abnormality on a single test for
detecting high grade lesions is 55% to 80% (National Cancer Institute). Since cervical
cancer is a slow progression, the sensitivity of a regular pap testing is likely higher
(National Cancer Institute).
To determine the sensitivity and specificity of the Pap test, both test threshold and
reference standard threshold must be defined. The test threshold is the point at which the
test will be considered positive and a reference standard threshold is the point at which the
reference standard is considered positive (National Cancer Institute). In practice, ASCUS is
often used as the test threshold, and CIN 1 is often used as the reference threshold (National
Cancer Institute). This gives a sensitivity of about 68% and specificity of about 75%
(National Cancer Institute). The more appropriate test threshold is LSIL with a reference
threshold of CIN 2-3 which gives a sensitivity of 70% to 80% with a specificity of about
95% (National Cancer Institute).
Testing for HPV as a primary screening test has been FDA approved only in
concurrence with Pap test in women aged 30 years and older (National Cancer Institute).
Numerous studies have shown that compared to Pap test, HPV test has more sensitivity
(84% to 97%) (National Cancer Institute). In one randomized study where both Pap and
HPV testing was done among women aged 30 to 69 years showed sensitivity of HPV was
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CERVICAL CANCER SCREENING AND THE COMMUNITY
95% compared to 55% of Pap test (National Cancer Institute). The combination of HPV
and Pap test had 100% sensitivity and referral rate of 7.9% (National Cancer Institute). A
study titled, “The performance of human papillomavirus high-risk DNA testing in the
screening and diagnostic settings,” evaluated the performance of HPV test in patients 30
years and older. There were 835 participants screened based on Pap test results. The results
showed sensitivity of 69% and specificity of 93% (Cardenas-Turanzas, et al, 2008). The
LR+ was 10.24 and LR- was 0.34 (Cardenas-Turanzas, et al, 2008).
Cervical Screening Tests and Ethical Considerations
Cervical cancer screening has led to a significant reduction in mortality of the
disease. It requires involvement of all health professionals and ethics. Public health
professional such as an epidemiologist must consider patient confidentiality important on
the bases of ethics. Next, all patients should be treated equal and not based on their health
insurance or socioeconomic status. It is only ethical to provide cervical cancer screening to
all women.
Recommendations
Cervical Cancer Screening Tests Recommendation
As we learned, the two screening tests for cervical cancer are Pap test and the HPV
test. I would recommend these tests to all women from ages 21 to 65 (HPV test: 30-65).
These tests are not recommended for women who have had a hysterectomy. In the city of
Chicago, I think the target population to concentrate on these tests would be women with
low socioeconomic status. I believe low socioeconomic has a relationship to low education,
minorities and uninsured. These are the most vulnerable factors to developing cervical
cancer. Therefore, I would recommend these women to have access to screening tests.
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CERVICAL CANCER SCREENING AND THE COMMUNITY
Increasing Participation in Cervical Cancer Screening Tests
To increase participation levels in cervical cancer screening, more awareness of the
disease and the screening itself is needed. Providing education in school, hospital and
clinics about the disease and screening methods would get people involved in the screening
actions. This education should be provided for not only women but even men so they are
aware of such disease and can help prevent it for his loved ones. In addition to educating
the public, providing more information such as referrals to places that offer free or reduced
price screening to people that need it is important.
Public Health in Increasing Screening Participation
Public health role in increasing screening participation should not be limited to
education or funding. Public health has opportunities to ensure that participation in cancer
screening is widespread. Public health can open more systems that allow women to get
screened. For example, the Illinois Breast and Cervical Cancer Program (IBCP) offers free
pelvic examination and Pap smear to eligible women: 35-64 years of age, noninsured,
underinsured and not receiving services through Medicare Part B (City of Chicago).
Women who are younger than 35 who have a history of abnormal Pap test may be enrolled
in the IBCCP (City of Chicago). The most important action public health can take to
increase screening participation is limit the social differences. Once this is done,
participation will increase on its own.
Conclusion
Along with the screening methods, prevention methods should also be applied to
cervical cancer. There are two types of vaccine available, the gardasil and the cervarix,
which prevents the most common types of HPV virus. It is recommended to be given to
preteen girls at the age of 11 or 12 to 26 so they are protected before ever being exposed to
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CERVICAL CANCER SCREENING AND THE COMMUNITY
the virus (Center of Disease Control and Prevention, 2014). The HPV vaccine is given in 3
shots.
The three core functions of public health, assessment, policy development, and
assurance, work together all around to make a healthy community. Examples of essential
services of public health include, monitor, educate, enforce, evaluate and research. With
public health professionals working together, we will have a bright future.
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References
Cardenas-Turanzas, M., Noqueras-Gonzales, G.M., Scheurer, M.E., Adler-Storthz, K., Benedet,
J.L, Beck, J.R., Follen, M., Cantor, S.B. (2008). The performance of human
papillomavirus high risk DNA testing in the screening and diagnostic settings. Cancer
Epidemiology Biomarkers and Prevention, 17(10): 2865-2871. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/18843032.
Center of Disease Control and Prevention. (2014). Gynecologic Cancers: Cervical cancer.
Retrieved from http://www.cdc.gov/cancer/cervical/.
Center of Disease Control and Prevention. (2014). Gynecologic Cancers: Cancer screening in the
United States. Retrieved from
http://www.cdc.gov/cancer/cervical/what_cdc_is_doing/screening_us.htm.
Center of Disease Control and Prevention. (2014). Gynecologic Cancers: Cervical cancer rates
by race and ethnicity. Retrieved from
http://www.cdc.gov/cancer/cervical/statistics/race.htm.
Center of Disease Control and Prevention. (2014). Gynecologic Cancers: Cervical Cancer
Screening Rates. Retrieved from
http://www.cdc.gov/cancer/cervical/statistics/screening.htm.
Center of Disease Control and Prevention. (2014). Gynecologic Cancers: What should I know
about screening. Retrieved from
http://www.cdc.gov/cancer/cervical/basic_info/screening.htm.
Center of Disease Control and Prevention. (2014). Preteen and Teen Vaccines: HPV Vaccine for
Preteens and Teens. Retrieved from
http://www.cdc.gov/vaccines/who/teens/vaccines/hpv.html.
City of Chicago. (2010). Get a Pelvic Exam and a Pap Smear. Retrieved from
http://www.cityofchicago.org/city/en/depts/cdph/provdrs/clinic/svcs/get_a_pelvic_exama
ndapapsmear.html.
MedicineNet. (2014). Cervical Cancer. Retrieved from
http://www.medicinenet.com/cervical_cancer/page4.htm#diagnosis.
National Cancer Institute. (2014). Cervical Cancer Screening. National Institutes of Health.
Retrieved from
http://www.cancer.gov/cancertopics/pdq/screening/cervical/HealthProfessional/page2.
National Cervical Cancer Coalition. (2014). Screening: Pap and HPV Tests. American Sexual
Health Association. Retrieved from http://www.nccc-online.org/index.php/screening.