Transcript: Pap Screening In Primary Care

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Transcript

Liz Rohr:
Well, hey, there, it's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

Liz Rohr:
In this episode, I'm going to be talking about Pap smears. So first I'm going to start with some context that is helpful to know and fun to know, but also helps to educate our patients. Next, I want to jump into interpretation, some potential results that you might see on a Pap and what to do with them, plus my favorite resource. And a little bit about the management pieces, like the management, it gets outside of the scope of primary care. We won't necessarily be deciding that management. However, it's important to know, and understand how that process works so that we can adequately counsel our patients and support them when they're going through that process.

Liz Rohr:
So, first up, I want to talk about some context. So cervical cancer screening, Pap screening is the sampling of cervical cells to assess for cervical cancer. It currently stands that in the screening guidelines, there are a number of screening guidelines in the US, which may be a topic for another video of which organization to follow their recommendations, but another topic for another day.

Liz Rohr:
But the USPSTF, United States Preventive Services Task Force, recommend cervical cancer screening starting for patients with a cervix starting at ages 21 to 65. So for patients who are 21 to 30, those patients are recommended to get cervical cytology every three years. So what that means is just a sampling with a cytobrush sent to the lab, cells only, every three years, if it is normal expected findings.

Liz Rohr:
For patients who are 30 and above, as it currently stands, is that they can either do continued cervical cytology testing alone, only looking for cervical cells. They can do combined co-testing of cervical cells as well as HPV, the virus, human papillomavirus. That's every five years. Or they could do HPV testing by itself every five years. So those are the screening recommendations.

Liz Rohr:
So I want to get into a little bit of background though, just so you can help counsel your patients. So cervical cancer is actually, when it comes on the list of top causes of cancer in the United States, it was about 19. Number one is breast cancer. That's about 20 times the number of cases and deaths-ish, don't quote me in the deaths, but incidents definitely about 20 times. And so it's like, why is there this big thing and stressor about cervical cancer screening and why is it so rigorous and all that stuff?

Liz Rohr:
Obviously, I want to take care of all of our patients and all the different types of cancers. For context, in countries that don't have cervical cancer screening, it's the number two cause of cancer and death in patients with a cervix. So that's why we do cervical cancer screening. That's why it's number 19. So since we've implemented cervical cancer screening over the last 50 years, I believe it's both morbidity and mortality or incidence of mortality rather, has decreased by about 75%. So it's way lower in the United States where we have that general testing.

Liz Rohr:
So a little note about HPV. So there are about 40 types of human papillomavirus. 15 of them are the most serious ones, the highest risks being the 16 and 18 one. It is the 99% of cases of cervical cancer also are caused by HPV. It's the number one cause of cervical cancer. So that's why we care about it, kind of two pearls about it though.

Liz Rohr:
Most of the time by the age of 30, patients have cleared it on their own. It's a sexually transmitted virus that we are exposed to and our immune system can get rid of it or it cannot get rid of it. So that's why we don't test for HPV under the age of 30 is because if it's going to be there, if they have it, it's still going to be there. And it's like, okay, great. We'll see how they feel and how we test when they're age 30, because it's not actively causing issues at that time.

Liz Rohr:
Which leads them to the other pearl, which is that it takes about 15 years for cervical cancer to progress to severe. And so that's really also important to let our patients know when it comes to the screening guidelines as well as the management guidelines is that even if somebody has HPV, it's not necessarily going to turn into severe cervical cancer before 15 years has elapsed.

Liz Rohr:
And then another little factoid is that about 50% of patients with cervical cancer have never had a Pap smear. Hopefully, this is helping. And this can also help you have those conversations with your patients that are like, "Do I really need to do that? I haven't done that, blah, blah, blah."

Liz Rohr:
So who's at the highest risk for cancer? So about 10% of patients with cervical cancer haven't had a Pap within five years. That's why we have that five-year mark. Patients who are born outside of the US, or have only been inside the US for the last 10 years also at pretty high risk because again, different screening guidelines in the US versus worldwide. Lower socioeconomic status and patients who are not connected to healthcare definitely are at higher risk.

Liz Rohr:
There's also racial and ethnic disparities. So as you may or may not know, race is a social construct. It's a poor proxy for familial and genetic history. And it's not like it's just a social thing. It's not like a biological thing. But however, there are trends for patients who identify in various racial and ethnic groups.

Liz Rohr:
So there's a higher incidence of both cervical cancer and mortality among Latino Americans, non-Latino Black Americans, as well as American Indian and Alaskan Native patients. So those are the highest risk patients or highest incidents in mortality. Followed by non-Latino white Americans and lowest incidents and mortalities among Asian Americans and Pacific Islander Americans.

Liz Rohr:
So those are just important things to note. So when you're just keeping in the back of your mind as you're working with patients, because at least in the context of primary care, there's so many boxes to check and so many things to think about all the time like, "Oh, I forgot to do that cervical cancer screening." "I forgot to do their Pap. They're due for their Pap, I'll get it next time." That happens. That's normal. That's okay. And also like, let's keep this in the front of our minds that this is the reason why we have it under control in this country.

Liz Rohr:
So let's jump in. So that's the context, just some helpful information let's get into interpretation. So when you get a Pap result, you're going to be looking at the cytology as well as the HPV results. I've already said with HPV, there's about 40 kinds. There's the higher risk kinds. On the result, it will let you know, what type it is and this is a high risk kind.

Liz Rohr:
The next part is the cytology, what kind of cells we're looking at. The most common and important ones to look at are those squamous cells. So typically, the kind of "normal" result is negative for intraepithelial lesion or malignancy, normal, or there's an epithelial cell abnormality. Those are the two kind of branching points, those two options. If there is an epithelial cell abnormality, there's going to be a couple of different options.

Liz Rohr:
Before I get into those options, I want to share my favorite resource. So the guidelines for management of abnormal Paps is through the ASCCP. They have the guidelines. Their algorithms are a little complicated to use and understand sometimes. However, they have developed and app. It's about $10 a year. I'm not affiliated with them in any way, but I do use it myself and I love it. And I recommend it and it's worth every penny.

Liz Rohr:
So totally check that out if you were obtaining Pap samples and interpreting them and managing them. And you want some help with that kind of reading through their different algorithms, which can be very mind-bendingly confusing. But this tells you exactly what to do. Beautiful, right? So when it comes to HPV, you just put in those results, that part, and then they'll handle that. The app, the guidelines will tell you what to do.

Liz Rohr:
The next piece is again, those results of the squamous cells. So I love this image because I think for me, when I was a student and becoming a new grad, I was like I don't really understand all of this like alphabet soup of letters. But when I can see what it looks like, then it's a lot more helpful.

Liz Rohr:
So the first step in terms of abnormality is something called ASCUS, so it's atypical cells of undetermined significance. It's a mouthful, but basically it is what it sounds like. It's just, we don't know. It's slightly abnormal, but it's not really anything specific enough to tell you more. It's just something that you want to keep an eye on because it could develop into those later stages. Again, cervical cancer, severe cervical cancer can take 15 years to develop.

Liz Rohr:
Next step in terms of that going up the scale of like more abnormal looking cells is low-grade squamous intraepithelial lesion, LSIL. Next step is high-grade. So it goes ASCUS, low-grade, and then high-grade. High-grade squamous intraepithelial lesion, so that is HSIL. You may actually see squamous cell carcinoma on your Pap. I have never seen that. It is an option.

Liz Rohr:
And basically what happens when you'd get those results, the HPV results and the ASCUS, LSIL, HSIL, you plug in the information in the app. Plug in their age, and then it really just spits out what you do next. I'm going to talk a little bit about what you do next for the abnormals, but I want to pause and talk about a couple of different other things you might find on your Pap sample that are a little bit tricky.

Liz Rohr:
So one of them that comes up, it's not all the time, I think it's like 10% to 20% actually is the stats that I found, something it's called absent endocervical cells/transformation zone. That might look different on your labs. It might be worded a little bit differently, but basically that transformation zone, that squamocolumnar junction ... I'm really good at mispronouncing things, but hopefully I got that one ... is a high risk for neoplasia.

Liz Rohr:
So we do want to see that on a Pap sample. However, it cannot be there and that's okay. So ASCCP recommends, it depends on their HPV result. If their HPV is negative or it was not obtained because it was not indicated because they're under the age of 30, you just return to regular screening. If they do have HPV, you follow those guidelines. But it's not necessarily a need to immediately repeat it. It can be uncomfortable. It could feel uncomfortable to do that, but those are the guidelines. It's a little bit controversial, but there's not enough data to suggest that those patients warrant more testing because it could lead to more problems.

Liz Rohr:
You may also see something called glandular cell abnormalities. So I'm not going to get into each of the specifics in this episode, but definitely that is an option. And it's kind of similar to the squamous cell ones where there are just different levels of like how severe it is. We always want to look into glandular cell abnormalities. Just moral of the story, just remember that piece.

Liz Rohr:
Two other things I want to talk about. One is about sampling. So excessive blood or excessive lubricant can really obscure the cytology. And so you want to be mindful, a clinical pearl here, is being really mindful of what kind of lubricant you are authorized to use by your supervisor.

Liz Rohr:
Sometimes there are specific types of lubricant that is more amenable to cytology. And sometimes you just have to use a lot less. You don't want your patients to be uncomfortable, but at the same time, we don't want to interfere with the sample and then they have to repeat the test again. That's maybe even more uncomfortable, who knows.

Liz Rohr:
So the next thing is about bacterial findings or other organism findings. This happens a fair amount. I'm not going to get into every single thing that you might see, but I'm going to touch on the most common ones that I see in primary care. So the moral of the story when it comes to an organism, most of the time you want to clinically examine the patient and pursue the appropriate diagnosis for that indication. Basically, what I mean is like just because you find it on a Pap doesn't mean they have it and that you treat it, for the most part. I'll get into some specifics.

Liz Rohr:
So trichomonas, the specificity is high enough that it's reasonable to treat trichomonas if you incidentally find it on a Pap. However, you may see something, it might be worded differently. I've seen it worded differently in different places, but basically, it's a shift in bacilli suggestive of BV. The consensus is that's not sufficient enough to diagnose a patient with that, so you want to clinically assess them and then consider further testing. And it doesn't always turn out that they have BV. It's just in that sample. You want to just investigate that further before you like snap treat them.

Liz Rohr:
You may see things like reactive changes in inflammation. That doesn't necessarily mean much. And according to my research, further testing is not indicated. So that doesn't necessarily mean you have to go down this rabbit hole of like, oh my gosh, they have a hidden infection, that kind of thing.

Liz Rohr:
So actinomyces, pretty sure I'm saying that right, is a bacteria that is a normal gastrointestinal flora. It is especially seen with patients who have an IUD. And it's a little bit controversial, but the thought is that it's a colonizer. And again, moral of the story is you want to assess the patient and then you want to see like, do they have clinical symptoms? Do they have symptoms suggestive of PID? And then you want to do a vaginal culture for actinomyces, if you're going down that route.

Liz Rohr:
But it looks like there's differing opinions based on like, do we always culture everybody who comes up with actinomyces versus is it a really clinical assessment of do they need it or not? And you just let the patient know. It's kind of a patient-guided decision-making process.

Liz Rohr:
So I want to touch a little bit on the management. So like I said, I always use that ASCCP app. And it's really helpful for like step one, two, three, four. Most of the time when patients have an abnormal Pap, they're going to first do a colposcopy. If you haven't had the pleasure of observing a colposcopy or performing a colposcopy, I just want to tell you a little bit about it. I love procedures and I do mean that sincerely, the pleasure of doing it because I love procedures. Although I do acknowledge it is not like a very comfortable procedure for patients, and so it's a little bit hard to watch in that way.

Liz Rohr:
But basically it's an extended Pap exam. I do recommend that you shadow one if you haven't had the opportunity so that you can kind of counsel patients appropriately. Even if you don't end up doing them yourself, you can. If you do ... Sorry, let me pause there.

Liz Rohr:
If you do want to do this, I do have a number of family medicine colleagues who have gone through this training to observe and do their own about 25 times with supervision, and then they are allowed to do it in the clinic setting. I have not had that opportunity because of limited need for colposcopy in my clinic and not in a need for another provider and extended training, et cetera. But you could, if you wanted to.

Liz Rohr:
Anyway, so colposcopy, you could do it in primary care if you have somebody who's trained, or you can send them to gynecology. And it's an extended Pap and they use a variety of different liquids and acetic acid. And they're looking for, like they spray acetic acid on the cervix and then they're looking for like little white spots. And then they look with a green light and then like a different light. I don't know the whole procedure, but basically, it's like a bunch of whole liquids. They look with different lights and then they take little samples of a biopsy.

Liz Rohr:
They don't give them anesthesia, which is indicated. I don't want to go on a tangent there, but it's not like that's pretty standard for a variety of reasons. But it's basically just a very quick pinch of tissue and it's not very comfortable for patients, but it's also ... Anyway, it's not very comfortable. The other thing that they'll do is a sampling of the endocervical cells. That is not very comfortable, but it's basically like a uterine sound only with a special brush.

Liz Rohr:
When you get the colposcopy results from those biopsies, you might get a result called cervical intraepithelial neoplasia, so CIN. So if you look at the image of the abnormal cells, when it gets to that really abnormal stage, it's not quite to the place of cancer. This is still a pre-malignant lesion, and levels one to three determine how severe it is.

Liz Rohr:
For those patients, there's a procedure, there are two different kind of treatment options. Basically, what we're trying to do is prevent those pre-malignant lesions from turning into cancer. And so there's kind of two different options. One is an excision procedure, and one is an ablative procedure. So there's two main excisional procedures. One is called a cone, one is called a LEEP. Those are nicknames.

Liz Rohr:
So it's a cone biopsy, also known as cervical conization, cold knife conization. Those are all the different names for it. And you can Google a picture of it, like not like a real patient because that might be not your thing. But you could do an illustration, they have them. But basically they're taking a sample of the cervix to get rid of those cells. This is under general anesthesia and a day surgery type of setting.

Liz Rohr:
The other option, LEEP, is a loop electrosurgical excision procedure. It's just the same procedure done slightly differently. Again, also under general anesthesia. And then the other option is something like cryotherapy, like that ablative type of thing. There's a couple of different treatments for that. But most of the patients that I see in primary care have either that LEEP or cone procedure.

Liz Rohr:
So yeah, so that is my spiel about Paps. Hopefully, that is helpful. If you haven't grabbed the ultimate resource guide for the New NP head over to realworldnp.com/guide. You'll get these episodes and straight to your inbox every week with notes from me, patient stories, and bonuses I really just don't share anywhere else.

Liz Rohr:
Thank you so much for tuning in. Hang in there, I'll see you soon.