NR 503 Week 2 Discussion

From the U.S. Preventive Task Force website https://www.uspreventiveservicestaskforce.org/BrowseRec/Index (Links to an external site.)Links to an external site., choose one screening test that might be considered in primary care.

Define the test, its positive predictive value, reliability and validity. Discuss patient medical or family history that may alter your recommendation for screening?

A Papanicolaou test or better known as Pap smear testing is a method of cervical cancer screening. It is used to detect cervical epithelial changes that can be pre-cancerous and cancerous (Sachan, Singh, Patel, & Sachan, 2018). There are two forms of cervical screening testing, conventional and liquid-based cytology. There is no clinical or significant difference in the results. As with any testing and results, there can be a potential false-positive or a false-negative. In essence, one is not better than the other. Both methods share the same high accuracy rate. If further testing is needed a colposcopy is performed as the diagnostic test.

Cervical cancer screening consist of cytology (Pap smear) for women with a cervix at ages 21-29 every 3 years and for women 30 to 65 cytology every 3 years or cytology with human papilloma virus (HPV) every 5 years. There has been a large reduction rate of cervical cancers in the United States. Early screening and detection reduces cervical rates 60% to 90% within 3 years of interventions (U.S. Preventive Services Task Force [USPSTF], 2012). Unfortunately, for developing countries cervical cancer is higher due to the lack of knowledge, technology, and experience.

“The overall sensitivity of the Pap test in detecting a high-grade squamous intraepithelial lesion (HSIL) is 70.2%. A Pap screening done in association with a HPV DNA test increases the sensitivity for early detection of precancerous lesions” (Sachan, Singh, Patel, & Sachan, 2018). There can be 6 different pap results, I will list the severity in ascending order: negative, atypical squamous cells (ASC-US), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), atypical squamous cells-cannot exclude HSIL (ASC-H), and atypical glandular cells (ACG) (The American College of Obstetrician and Gynecologists [ACOG], 2016). Depending on the results and the patient’s age will depend on if a colposcopy, biopsy, or an endocervical sampling is needed.

Situations that can alter the screening for this patient is having a total hysterectomy (medical history). It is not recommended a pap smear be performed on someone without a cervix due to a lack of cervical precancerous lesions. Another alteration could be if their immediate family member has been diagnosed with cancer early in life (family history). If a patient is HIV positive they may require more frequent screening. Also, the patient’s age. Studies have found screening prior to age 21 and after age 65 with previous normal Pap smear results is not beneficial. The risk outweighs the benefits and can potentially cause physical and/or psychological damage.

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Reference

  The American College of Obstetrician and Gynecologists. (2016). Abnormal cervical cancer screening test results. Retrieved from https://www.acog.org

Sachan, P.L., Singh, M., Patel, M.L., & Sachan, R. (2018). A study on cervical cancer screening using pap smear test and clinical correlation. Asia-Pacific Journal of Oncology Nursing, 5(3), 337-341.

U.S. Preventive Services Task Force. (2012). Cervical Cancer: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org.

I enjoy reading your post, it was quite informative. Cancer is the second leading cause of death globally, and was responsible for 8.8 million deaths in 2015. Globally, nearly 1 in 6 deaths is due to cancer (WHO, 2018). Approximately 15% of cancers diagnosed in 2012 were attributed to carcinogenic infections, including Helicobacter pylori, Human papillomavirus (HPV), Hepatitis B virus, Hepatitis C virus, and Epstein-Barr virus (Plummer, Martel, Vignat, Ferlay, Bray, & Franceschi, 2016). More specifically, cervical cancer was a known cause of death for American women. However, this rate of death was decreased due to the use of the Pap test (WHO, 2018). It has been my experience that many young women visit the ED with vaginal complaints and have never obtained a Pap smear, let alone visit the gynecologist for these complaints. The challenge as a nurse is educating these young women on the importance of this screening.

The views or beliefs held by the young ladies are that they are not in need of this test, embarrassed, or just lack of knowledge. To enable a positive moment where the information presented is grasped by the female patient, the nurse should strive to provide education that stresses the importance of the Pap smear and strategies allowing greater understanding of one’s own body (Plummer et.al, 2016). Additionally, continue to build trust and allow for opportunities to plant the seeds of knowledge. 
Screening aims to identify individuals with abnormalities suggestive of a specific cancer or pre-cancer who have not developed any symptoms and refer them promptly for diagnosis and treatment. Screening programms can be effective for select cancer types when appropriate tests are used, implemented effectively, linked to other steps in the screening process and when quality is assured. In general, a screening program is a far more complex public health intervention compared to early diagnosis.

Examples of screening methods are: NR 503 Week 2 Discussion
visual inspection with acetic acid (VIA) for cervical cancer in low-income settings;
HPV testing for cervical cancer;
PAP cytology test for cervical cancer in middle- and high-income settings; and
mammography screening for breast cancer in settings with strong or relatively strong health systems.

  Plummer, M., Martel, C., Vignat, J., Ferlay, J., Bray, F., & Franceschi, S. (2016). Global burden of cancers attributable to infections in 2012: a synthetic analysis. Lancet Glob Health. 4(9):e609-16. doi: 10.1016/S2214-109X(16)30143-7.

World Health Organization (2018). Cancer. Retrieved from http://www.who.int/news-room/fact-sheets/detail/cancer on 07/18/2018

I would like to add the validity, reliability, and its predictive value found in a peer-reviewed journal. The article analyzed the effectiveness of a Pap smear. In a retrospective study with 266 cases were performed.

The overall sensitivity of Pap smear in cervical cytology in their study found to be as followed: sensitivity 74%, specificity 91%, positive predictive value 86%, negative predictive value 82.5%, false positive percentage 13%, false negative percentage 17.4% (Kudva, 2015). The article did mention possible errors that may have contributed to the under and over diagnosing of cervical cancer, such as sampling technique errors.

Kudva, R. (2015). Accuracy of pap smear predictions: Cytohistologic correlation. American Society for Clinical Pathology, 144

Thank you for your follow-up! This information is exactly what I was looking for this week. As you are learning this week, sensitivity and specificity are both characteristics of a test. There is always a trade-off between the two. In other words, a test may be more sensitive, but less specific and vice versa. For example, a test that’s very sensitive will pick up even the slightest abnormal finding. This means it will miss few cases of the disease, but it will also mistake some people as having the disease when they don’t. Unlike PPV and NPV, the sensitivity and specificity of diagnostic tests are not affected by the prevalence of the disease/condition.

Instead, they can be influenced by differences in disease characteristics (such as clinical severity or anatomic extent of a disease) and characteristics of patients such as age. As you discuss, the accuracy of a Pap screen greatly depends on the technique and collection method, affecting the quality of the test.  Also, the threshold utilized creates varied results regarding sensitivity, and specificity.  

Cancer screenings are an essential preventative measure to inform and continue educating communities.  Internationally, an estimated 530,000 new cases of cervical cancer are diagnosed each year, which result in 275,000 deaths; more than 80% of all cases of CC occur in developing countries (March & Holle, 2017). 

Dr. Anttila, depending on the sensitivity of a screening exam it can very well result in false positives because of the dire sensitively the test possesses.  Disease epidemiology can very well differ and look different in multiple individuals based of the pre-disposition of the individual; including what the individual has been exposed to.  Referring to cervical cancer, this can incorporate if the individual has ever been affected by a sexually transmitted infection as well as heredity factors that may be prevalent.  Early detection is key; though there may be certain cases of inaccuracy; pap smears have been reported to be 71%-81% when diagnosing abnormalities in patients.

    Reference

March, P. P., & Holle, M. O. (2017). Cervical Cancer: an Overview. CINAHL Nursing Guide

I really enjoyed reading your post and I think you mention some excellent points related to the importance of cervical cancer screening. As you mention cervical cancer in developing countries is higher especially in Nigeria. Cervical cancer is the second leading cause of mortality related to cancer in Nigeria which includes about 80% of of women dying or suffering from complications of this disease (Okunowo & Anorlu, 2018). As you stated cervical cancer is preventable and no women in this country or any other country should be dying of this.

Studies have shown that a large number of the women in developing countries are not even aware of screening for cervical cancer. A great percentage of the women who die of this cancer were not even aware of the pap smear screening test. Opportunistic screening is what is used in Nigeria which is a method that is aimed towards a small portion of women that can come in contact with a health care provider (Okunowo & Anorlu, 2018). Even though this type of screening is a great method to increase awareness and provide screening for this population it is not widely used. Thanks for your great post it really inspired me to learn more about cervical cancer screenings in other countries

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