Cervical Screening in Practice Case Studies

Learning objectives Demonstrate current knowledge of the National Cervical Screening Program (NCSP) and how this applies to clients

Case study 1 - Jenny Jenny 24 y.o. attends your clinic for a routine appointment, and you notice she is overdue for cervical screening. She received her full HPV vaccination in high school. She is hesitant to have a cervical test and not interested in taking part in cervical screening in the near future. What else would you like to know? Which points would you mention to help her understand the importance of regular cervical screening?

Cervical cancer in NSW Image : Accessed 2/6/17: https://www.cancerinstitute.org.au/understanding-cancer/cancer-in-nsw/cervical-cancer

Case study 2 You work in a general practice in an area with a large population of patients that are Aboriginal and Torres Strait Islander. You’re concerned about low rates of uptake of cervical screening in this group of women. What strategies could you implement to increase participation rates amongst Aboriginal and Torres Strait Islander women?

Case study 3 - Judith Judith is 42 and lives in a rural town. She has travelled more than two hours to your practice with a chest infection It has been eight or nine years since her last test. She explains that she is not comfortable screening with her local (male) GP Judith is adamant that she does not want cervical screening performed during her visit today What options are open to Judith? What information should you give her with respect to self-collection? Judith IS ELIGIBLE for self-collection because…. Judith is 30 years of age or over Judith is overdue for cervical screening by 2+ years Judith has declined a clinician-collected cervical sample Advise women if they have oncogenic HPV (not 16/18) detected, to return for a clinician-collected cervical sample for LBC testing to determine further management Women who have oncogenic HPV (16/18) detected will be referred directly for colposcopy, and a cervical sample for LBC should be collected at the time of that consultation. Judith needs to know that if viral DNA is found in the sample, will need to see a health professional for collection of the cervical sample

Case study 4 - Aya Aya is a 26 y.o. student who had a Pap test 2 years ago (NAD). She returns for another Pap test in January 2018. You inform her about the changes to NCSP, and she expresses concern about moving form biannual to 5-yearly screening. How would you approach this situation? What would you need to explain to Aya? How would you address her concerns re: transition?

Case study 5 - Kim Kim presents for her routine cervical screening test but during your history taking discloses a 4-month history of intermittent post-coital bleeding. She has been together with her male partner for 1 year, and has used COCP for the last 6 months. What’s your management plan? REFER Take a clinical, sexual and cervical screening history Consider chlamydia, other STIs Examine cervix Investigations to exclude genital tract malignancy: may include a HPV plus LBC co-test Pre-menopausal women with a single episode of PCB and a clinically normal cervix do not need colposcopy if co-test is negative If PCB / IMB recurs despite a negative co-test refer to gynaecologist Refer postmenopausal women with any vaginal bleeding for specialist assessment

Case study 6 – Lucy, 36 Lucy comes to see you in December 2017 Case study 6 – Lucy, 36 Lucy comes to see you in December 2017. She had a LLETZ procedure for CIN2 in mid-December 2014. Her last 2 PAP smears since then have been NAD, and she does not recall having HPV testing since her LLETZ procedure. What tests should Lucy have from now on? LLETZ = large loop excision of the transformation zone CIN2 = cervical intraepithelial neoplasia grade 2

Lucy does not appear to have had the Test of Cure as per previous post-treatment management recommendations, based on NHMRC guidelines 2005: Lucy needs to complete the Test of Cure: Dec 2017 – HPV DNA and LBC Dec 2018 – HPV DNA and LBC If both Negative, can go to 5-yearly cervical screening Cytology Colposcopy HPV 4-6 months Y 12 months 24 months Annually thereafter until Cytology and HPV both NAD on two consecutive occasions

Case study 7 – Susan Susan has mild intellectual disability and lives in a group home. She is sexually active. Susan receives a letter inviting her to have the new cervical screening test and presents to your practice with her carer Mary. * How would you approach the conversation with Susan about the Cervical Screening Test? How could you support Susan in making the decision to have a cervical screening test for herself? How might you improve information sharing with carers? Establishing rapport facilitates the communication of information; helps build trust and familiarity to proceed with the consultation. To build rapport, pay attention to the small things, like greeting people when you enter a room and saying goodbye when you leave. Strategies for building good rapport include: Being clear about your role and the purpose of the interaction. Using a person's preferred name when speaking with them. Using a pleasant tone that is clear and precise. Explaining words and expressions that may be unfamiliar and not using jargon. Asking simple and clear questions. Using age-appropriate language. Avoid jargon and use words familiar to the other person. Conveying acceptance by showing interest and concern.. Speak slowly and leave pauses for the person to process your words. Speak directly to the person concerned; they are central place in the communication. Speak in clear, short sentences and use simple words. Pause to enable the person to process what you are saying. Avoid long, complex sentences, technical words or jargon. Ask one question at a time and provide adequate time for the person to process the question and then formulate and communicate their response. If the person uses a communication device, ensure they have access to it, read the directions (usually on or in the device/book) and use it with them. If it is necessary to obtain part/all of the history from the carer maintain the focus on the person with the disability through your eye contact, body language and/or touch. Queensland Council of Social Services (2017). Utilise specialist communication skills to build relationships. http://etraining.communitydoor.org.au/mod/page/view.php?id=114

Barriers to Screening Geographical Psychosocial Economical Poor understanding Access to services Cultural Previous negative experience/sexual assault Fear of result Embarrassment Fear of pain Cost Time constraints Cancer prevention Menstruation Asymptomatic Health priority

FPNSW resources Talkline: phone 1300 658 886 Reproductive and Sexual Health: an Australian Clinical Practice Handbook 3rd edition Fact Sheets: Cervical Screening and HPV vaccination https://www.fpnsw.org.au/health-information/individuals/pap-test-and-cervical-screening Everything you need to know about the changes to NSCP National Cervical Screening Program (includes information in different languages) http://www.cancerscreening.gov.au/cervical