Post-Conference Session Summaries

Advances in the Prevention of Cervical Cancer

Instructional Session 8, presented Tuesday, April 24

Speaker Nora Katurakes, RN, MSN, OCN ^®, said that nearly all cases of cervical cancer are caused by persistent oncogenic human papilloma virus (HPV) infection. The primary cause of the cancer is persistent infection of any of 15 subtypes of HPV, specifically subtypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 58, 59, 68, 73, and 82 (subtypes 16 and 18 are the most common). Secondary risk factors for the disease are smoking, immunosuppression from medication or HIV infection, long-term use of oral contraceptives, multiple sex partners, or early sex debut.

Screening should begin three years after a woman first has vaginal intercourse but no later than age 21. From age 21–30, women should receive regular Papanicolaou tests (Pap tests) every year or liquid-based Pap tests every two years. After age 30, women can be screened every two to three years if they have had normal Pap test results. African American women with cervical cancer have higher mortality rates, yet approximately one-third do not participate in the recommended screening. Hispanic or Latino women have higher incidence rates. Women report that cost, cultural or belief system, lack of knowledge, and pain are common barriers to screening.

Cervical cancer is often asymptomatic until it reaches advanced stages. Symptoms that may develop include abnormal vaginal bleeding or watery discharge, heavy bleeding during or between menses, bloody or foul smelling discharge, lower-extremity edema or pain, and pelvic mass. All stages of cervical cancer are treated with radiation therapy, usually with chemosensitization. Early-stage disease can be surgically treated with positive results, but locally advanced stages must be treated with chemoradiation. Distant metastases are treated with chemotherapy or radiation for palliation only.

Susan Temple, RN, MSN, AOCN ^®, discussed the HPV vaccine for the prevention of cervical cancer. The vaccine offers full benefit if patients have not been exposed to the HPV subtypes in the vaccine, so patients should be vaccinated before they become sexually active. Although the series of vaccines can be administered in females as young as nine, the recommendation is to start the series in patients aged 11–12 years. Females aged 13–26 can “catch up” on the vaccine but may not receive the full benefit if they have already been exposed to HPV.

Temple stressed that the vaccine will reduce the risk of cervical cancer but not eliminate it completely. Also, researchers are unsure how long the vaccine's protection against cancer is effective. Barriers include the vaccine's cost (approximately $360 for the three-dose series) and concerns that the protection it offers may lead to increased sexual activity and unsafe behaviors. Education of healthcare providers, policy makers, and the general public may help alleviate concerns.

Linda Krebs, RN, PhD, AOCN ^®, FAAN, presented information on the global reach of cervical cancer. In developing countries, cervical cancer accounts for 15% of all female cancers, survival is 41%, and 95% of women have never been screened. By comparison, cervical cancer accounts for 3.6% of new cancers in developed countries, survival is 61%, and most women have been screened for the disease. Because women in developing countries often are not screened, Krebs said that if healthcare providers have only one opportunity to screen them, it should be around age 35. Because cost is a barrier, Krebs recommended using cost-effective screen-and-treat methods, such as HPV DNA testing, visual inspection with acetic acid or Lugol's solution, or treatment of lesions with cryotherapy. Barriers also exist regarding the use of HPV vaccination in developing countries. Cost and availability are factors, as is compliance with administration (currently recommended as a three-injection series).

Oncology nurses can help by raising awareness, offering health education and counseling, recognizing screening opportunities, providing referrals and follow-up, and offering assistance with resources.