Pap Screening in Primary Care
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Show notes:
Pap screening in primary care-- how can such a common primary care intervention cause so much confusion? How often to screen, how to understand any findings that are not black and white, how to advise your patient about next steps – you would not be the first NP to feel overwhelmed with abnormal pap results in your inbox.
How to Interpret and Manage Abnormal Pap Results
Like so many other things in healthcare, the results – even when normal – can quickly become a confusing alphabet soup of abbreviations. Did you know that there isn’t even one universal definition of normal when it comes to pap results? It depends on the patient, their age, any co-testing you did, and more. Like a test in nursing school, there is never a YES/NO answer.
This week, we’ll take some of the mystery out of this challenging clinical topic, and help you understand the main points that will guide your treatment. We’ll talk about:
Current guidelines, and how they apply to your patient (and our favorite plug-and-play tool to make interpreting pap results super easy!)
The role of HPV in understanding pap results
Next steps for the patient with an abnormal pap result
Colposcopies, LEEPs, advanced sampling – what they are and how to explain them to your patient
Pro tips for interpreting results and guiding your patient
It’s true that even seasoned providers get stumped trying to navigate abnormal pap results. With time, practice, and a few tools in your toolbox, you will get more clarity on interpreting abnormal pap results and knowing the right next steps for your patient.
If you liked this post, also check out:
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel confident,
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capable and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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In this episode, we're going to be talking about pap smears.
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So first I'm going to start with some context that is helpful to know and fun
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to know, but also helps to educate our patients.
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Next, I want to jump into interpretation, some potential results that you might see
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on a pap and what to do with them.
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Plus my favorite resource and a little bit about the management pieces like the
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management.
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It gets outside of the scope of primary care, like we won't necessarily be deciding
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that management.
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However, it's important to know and understand how that process works so that we can adequately
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counsel our patients and support them when they're going through that process.
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So first up, I want to talk about some context.
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So cervical cancer screening, pap screening is the sampling of cervical cells to assess
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for cervical cancer.
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It currently stands that in the screening guidelines, there are a number of screening
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guidelines in the US, which may be a topic for another video of like which organization
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to follow their recommendations, but another topic for another day.
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But the USPSTF, United States Preventative Services Task Force, recommends cervical cancer
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screening starting for patients with a cervix starting at ages 21 to 65.
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So for patients who are 21 to 30, those patients are recommended to get cervical
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cytology every three years.
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So what that means is just a sampling with a cyto brush sent to the lab, cells only
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every three years, if it is normal expected findings.
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For patients who are 30 and above, as it currently stands, is that they can either do continued
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cervical cytology testing alone, only looking for cervical cells.
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They can do combined co-testing of cervical cells as well as HPV, the virus, human
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papillomavirus, or that's every five years, or they could do HPV testing by itself every
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five years.
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So those are the screening recommendations.
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So I want to get into a little bit of background, though, just so you can help
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counsel your patients.
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So cervical cancer is actually, when it comes on the list of top causes of cancer
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in the United States, it was about 19.
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Number one is breast cancer as about 20 times the number of cases and deaths ish.
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Don't quote me on the deaths, but incidents, definitely about 20 times.
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And so it's like, oh, like, why is there this like big thing and stressor about
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cervical cancer screening?
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And why is it so rigorous and all that stuff?
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Right.
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We obviously want to take care of all of our patients and all the different types
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of cancers for context in countries that don't have cervical cancer screening.
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It's the number two cause of cancer and death in patients with a cervix.
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Right.
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So that's why we do cervical cancer screening.
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That's why it's number 19.
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So since we've implemented cervical cancer screening over the last 50 years, I
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believe it's both morbidity and mortality or incidents and mortality rather has
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decreased by about 75 percent.
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So it's way lower in the United States where we have that general testing.
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So a little note about HPV.
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So there are about 40 types of human papilloma virus.
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Fifteen of them are the most serious ones.
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The highest risks being the 16 and 18 one.
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It is the 99 percent of cases of cervical cancer are also are caused by HPV.
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It's the number one cause of cervical cancer.
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So that's why we care about it.
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Kind of two pearls about it, though.
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Most of the time, by the age of 30, patients have cleared it on their own.
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It's a sexually transmitted virus that we are exposed to and our immune system
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can get rid of it or it cannot get rid of it.
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So that's why we don't test for HPV under the age of 30 is because if it's
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going to be there, if they have it, it's still going to be there.
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And that's it's like, okay, great.
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We'll see how they feel and how we test when they're age 30, because it's
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not actively causing issues at that time, which it leads me to the other
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which is that it takes about 15 years, 15 years for it, for cervical cancer
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to progress to severe.
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And so that's really also important to let our patients know when it comes to
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the screening guidelines, as well as the management guidelines is that even
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if somebody has HPV, it's not necessarily going to turn into severe
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cervical cancer before 15 years has elapsed.
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And then another little factoid is that about 50% of patients with
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cervical cancer have never had a pap smear.
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Hopefully this is helping, right?
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And this can also help you have those conversations with your
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patients are like, do I really need to do that?
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I haven't done that, blah, blah, blah.
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So who's at the highest risk for cancer?
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So about 10% of patients with cervical cancer haven't had a pap within five
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years, that's why we have that five year mark.
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Patients who are born outside of the U S or have only been inside
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the U S for the last 10 years, also at pretty high risk, because again,
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different screening guidelines in the U S versus worldwide lower socioeconomic
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status and not connected patients who are not connected to healthcare.
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Definitely aren't higher risk.
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There's also racial and ethnic disparities.
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So, um, as you may or may not know, race is a social construct.
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It's, it's a poor proxy for genetic, um, familial and genetic history.
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And it's not like, it's, it's just, it's just a social thing.
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It's not like a biological thing.
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So, but however, there are trends, uh, for patients who identify in
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racial and ethnic groups.
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So the highest, um, there's a higher incidence of both cervical cancer and
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mortality among Latino Americans, non-Latino black Americans, as well as
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American Indian and Alaskan native patients.
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So those are the highest risk patients or highest incidents and mortality
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followed by, um, non-Latino white Americans and lowest incidents and
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mortalities among Asian Americans and Pacific Islander Americans.
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So those are just important things to note, right?
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So when you're just keeping in the back of your mind, as you're, um,
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working with patients, because at least in the context of primary care,
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there's like so many boxes to check and so many things to think about all
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the time, like, oh, I forgot to do that cervical cancer screening, right?
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I forgot to do their pap, right?
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They're due for their pap.
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I'll get it next time.
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That happens, right?
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That's normal.
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That's okay.
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And also like, let's keep this in the front of our minds that like,
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this is the reason why we have it under control in this country, right?
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Okay.
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So let's jump in.
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So that's the context, just some helpful information.
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Let's get into interpretation.
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So when you get a pap result, you're going to be looking at the
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cytology as well as the HPV results.
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I've already said with HPV, there's about 40 kinds.
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There's the higher risk kinds on the result.
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It will let you know this is a, what type it is.
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And this is a high risk kind, right?
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The next part is like the cytology, like what kind of cells we're looking
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at the most common and important ones to look at are those squamous cells.
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So typically the kind of quote unquote normal result is negative for
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inter epithelial lesion or malignancy, normal, or there's
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an epithelial cell abnormality.
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Those are the two kind of like branching points, those two options.
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If there is an epithelial cell abnormality, there's going to
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be a couple of different options.
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Before I get into those options, I want to share my favorite resource.
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So the guidelines for management of abnormal PAPs is through the ASCCP.
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They have the guidelines.
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Their, their algorithms are a little complicated to use and understand
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sometimes, however, they have developed and developed an app.
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It's about $10 a year.
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I'm not affiliated with them in any way, but I do use it myself and I love it
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and I recommend it and it's worth every penny.
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So definitely check that out.
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If you were obtaining PAP samples and interpreting them and managing them.
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And you want some help with that kind of like reading through their
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different algorithms, which can be very like mind-bendingly confusing.
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But this tells you exactly what to do.
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Beautiful, right?
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So when it comes to HPV, you just put in those results, that part,
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and then they'll handle that, right?
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The app, the guidelines will tell you what to do.
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The next piece is, um, again, those results of the squamous cells.
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So I love this image, um, because I think for me, when I was a
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student and becoming a new grad, I was like, I don't really understand
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all of this like alphabet soup of letters, but when I can see what it
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looks like, then it's a lot more helpful.
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So the first step in terms of abnormality is something
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called Ascus, so it's atypical cells of undetermined significance.
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It's a mouthful, but basically it's like, it is what it sounds like.
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It's just, we don't know.
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It's slightly abnormal, but it's like not really anything
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specific enough to like tell you more.
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It's just something that you want to keep an eye on because it could
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develop into those later stages, right?
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Again, cervical cancer, severe cervical cancer can take 15 years to develop.
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Next step in terms of that, going up the scale of like more abnormal
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looking cells is low grade squamous intra epithelial lesion, LSIL.
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Next step is high grade.
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So it goes atypical, Ascus, low grade, and then high grade.
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High grade squamous, intra epithelial lesion.
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So those are, that is HSIL.
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You may actually see squamous cell carcinoma on your PAP.
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I have never seen that.
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It is an option.
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And basically what happens when you'd get those results, the
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HPV results and the Ascus LSIL, HSIL, you plug in the
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information in the app, plug in their age, and then it really
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just spits out what you do next.
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I'm going to talk a little bit about what you do next for the
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abnormals, but I want to pause and talk about a couple of different
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other things you might find on your PAP sample that are a little bit tricky.
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Okay.
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So one of them that comes up, it's not all the time.
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I think it's like 10 to 20% actually is like the, the stats that I found
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something it's called absent endocervical cells slash transformation zone.
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That might look different on your labs.
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It might be like worded a little bit differently, but basically that
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transformation zone, that squamous columnar junction, I'm really
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good at mispronouncing things, but hopefully I got that one.
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Um, is, is a high risk for neoplasia.
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So we do want to see that on a PAP sample.
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However, it can not be there and that's okay.
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So ASCCP recommends, it depends on their HPV result.
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If their HPV is negative or it was not obtained because it was not
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indicated because they're under the age of 30.
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You just return to regular screening.
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If they do have HPV, you follow those guidelines, but it's not necessarily
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a need to like immediately repeat it.
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It's can be uncomfortable.
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I could feel uncomfortable to do that, but those are the guidelines.
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It's a little bit controversial, but there's not enough data to
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suggest that those patients warrant more testing because it
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could lead to more problems.
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Right.
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Um, you may also see, um, something called glandular cell abnormalities.
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I'm not going to get into the, each of the specifics in this episode,
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but, um, uh, definitely like that is an option.
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And it's kind of similar to the squamous cell ones where there's different
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levels of like how severe it is.
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We always want to look into glandular cell abnormalities.
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So just, just more of a story.
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Just remember that piece.
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Two other things I want to talk about.
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One is about sampling.
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So excessive blood or excessive lubricant can really obscure the cytology.
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And so you want to be mindful or clinical pearl here is being really
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of what kind of, um, lubricant you are authorized to use by your supervisor.
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Sometimes there's specific types of lubricant that is more amenable to
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cytology, and sometimes you just have to use like a lot less.
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Like you don't want your patients to be uncomfortable, but at the same
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time, we don't want to interfere with the sample and then they
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have to repeat the test again.
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That's like more, maybe even more uncomfortable.
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Who knows?
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So, um, the next thing is about, um, like, uh, bacterial findings or
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other organism findings.
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This happens a fair amount.
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I'm not going to get into every single thing that you might see, but I'm
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going to touch on the most common ones that I see in primary care.
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So, um, the moral of the story, when it comes to an organism, most of
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the time, you want to clinically examine the patient and pursue the
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appropriate diagnosis for that indication, right?
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And basically what I mean is like, just cause you find it on the
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pap doesn't mean they have it and that you treat it for the most part.
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I'll get into some specifics.
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So trichomonas, the specificity is high enough that it's reasonable to
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treat trichomonas if you incidentally find it on a pap.
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However, you may see something, it might be worded differently.
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I've seen it worded differently in different places, but basically
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it's a shift in bacilli suggestive of BV.
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The consensus is that it's not, that's not sufficient enough
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to diagnose a patient with that.
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So you want to clinically assess them and then consider further
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testing and it doesn't always turn out that they have BV.
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It's just in that sample.
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You want to just investigate that further before you like snap treat them.
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You may see things like reactive changes and inflammation.
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That doesn't necessarily mean much.
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And it doesn't, and according to my research, further
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testing is not indicated.
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So that isn't necessarily mean you have to go down this
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rabbit hole of like, oh my gosh, they have a hidden
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infection and that kind of thing.
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So actinomyces, pretty sure I'm saying that right, is a bacteria
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that is a normal gastrointestinal flora.
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It is especially seen with patients who have an IUD and it's a little
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bit controversial, but the thought is, is that it's a colonizer and what
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you, again, more of the stories you want to assess the patient and then
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you want to see, like, do they have clinical symptoms?
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Uh, do they have symptoms suggestive of, of PID?
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And then you want to do a vaginal culture for actinomyces if
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you're going down that route.
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Um, but I saw, you know, it looks like there's differing opinions
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based on like, do we always culture everybody who comes up with actinomyces
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versus is it a really clinical assessment of do they need it or not?
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And you just let the patient know it's kind of a patient
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guided decision-making process.
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Okay.
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So I want to touch a little bit on the management.
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So, like I said, I always use that ASCCP app and, um, it's
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really helpful for like step one, two, three, four, most of the
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time when patients have an abnormal pap, they're going to
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first do a colposcopy.
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If you haven't had the pleasure of observing a colposcopy or
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form a colposcopy, I just want to tell you a little bit about it.
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Um, I love procedures and I do mean that sincerely the pleasure of
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doing it because I love procedures.
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Although I do acknowledge it is not like a very comfortable
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procedure for patients.
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And so it's a little bit hard to watch in that way.
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Um, but basically it's an extended pap exam.
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I do recommend that you shadow one if you haven't had the opportunity
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so that you can kind of counsel patients appropriately.
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Um, even if you don't end up doing them yourself, you can.
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If you do, sorry, let me pause there.
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If you do want to do this, I do have a number of family medicine
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colleagues who have gone through this training to observe and do their
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own about 25 times with supervision.
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And then they are allowed to do it in the clinic setting.
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I have not had the opportunity because of limited need for
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a colposcopy in my clinic and not in a need for another
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provider and extended training, et cetera, but you could, if you
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wanted to anyway, um, so a colposcopy, you could do it in
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primary care if you have somebody who's trained or you can send
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them to gynecology and it's an extended pap and they use a variety
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of different, um, like liquids and like acetic acid and they're
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looking for, like they spray acetic acid on the cervix and then
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they're looking for like little white spots and then they look
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with a green light and then like a different light.
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I don't know the whole procedure, but like basically it's like
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a bunch of whole liquids.
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They look with different lights and then they take
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little samples of a biopsy.
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Um, they don't give them anesthesia, which is, um, indicated.
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I don't want to go on a tangent there, but it's not like that's pretty
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standard, um, for a variety of reasons, but it's basically just
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a very, uh, quick pinch of tissue and is not very comfortable for
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patients, but it's also anyway, it's not very comfortable.
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Um, the other thing that they'll do is a sampling of the endocervical
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cells that is not very comfortable, but it's basically like a uterine
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sound only it's with a special brush.
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So after you get a colposcopy done, we look at the
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biopsy results and you might see something like CIN on there.
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Um, carcinoma, uh, cervical, when you get the colposcopy results
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from those biopsies, you might get a result called cervical
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inter epithelial neoplasia.
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So CIN.
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So if you look at the image of the abnormal cells, when it gets
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to that really abnormal stage, it's not quite to the place of cancer.
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This is still a pre malignant lesion and levels one to three,
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uh, determine how severe it is for those patients.
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There's a procedure.
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There are two different kind of treatment options.
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Basically what we're trying to do is prevent those pre malignant lesions
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from turning into cancer.
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And so there's kind of two different options.
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One is an excision procedure and one is an ablative procedure.
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So there's two main, uh, excisional procedures.
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One is called a cone when it's called a leap, those are nicknames.
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So it's a cone biopsy, also known as cervical conization, um, cold
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knife, conization, those are all the different names for it.
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And you can Google a picture of it.
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Like not like a real patient, cause that might be not your thing,
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but you could do an illustration.
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They have them, but basically they're taking a sample of the
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cervix to get rid of those cells.
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This is under general anesthesia and a day surgery type of setting.
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The other option leap is a loop electrosurgical excision procedure.
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It's just the same procedure done slightly differently.
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Again, also under general anesthesia.
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Um, and then the other option is something like cryotherapy,
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like that ablative type of thing.
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There's a couple of different treatments for that, but most of
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the patients that I see in primary care have either that loop or cone
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leap or cone procedure.
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So, um, so yeah, so that is, that is my, my spiel about PAPS.
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Hopefully that is helpful.
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If you haven't grabbed the ultimate resource guide for the new
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head over to realworldnp.com slash guide.
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with notes from me, patient stories and bonuses.
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00:18:44.950 --> 00:18:46.690
I really just don't share anywhere else.
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Thank you so much for tuning in.
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Hang in there.
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I'll see you soon.
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That's our episode for today.
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Thank you so much for listening.
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00:18:58.640 --> 00:19:02.220
Make sure you subscribe, leave a review and tell all your
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NP friends so together we can help as many nurse practitioners as
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possible, give the best care to their patients.
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00:19:08.720 --> 00:19:12.320
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the new NP head over to realworldnp.com slash guide.
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with notes from me, patient stories and extra bonuses.
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I really just don't share anywhere else.
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Thank you so much again for listening.
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Take care and talk soon.
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