At United Community & Family Services Pap Smear Tracking in Adult Primary Care At United Community & Family Services Christina C. Cheng Quinnipiac University Physician Assistant Program August 2010

Cervix Lower, narrow end of the uterus 3 layers: 2 cell types: serous membrane, muscular layer, mucous membrane 2 cell types: Squamous cells, columnar cells Cervix: lower, narrow end of the uterus (womb) Cancer: disease where cells have changed function or appearance – instead of dividing/growing at a controlled and orderly way, they grow out of control = mass, “tumor” Benign: only few cell layers Malignant: spreads to surrounding layers/tissues, organs Inner lining = mucous, thin, flat – squamous cells *** Mild cervical dysplasia – 1/3 Moderate cervical dysplasia – 2/3 Severe cervical dysplasia = CA in situ (CIS) – all layers  histo changes CIN: cervical intraepithelial neoplasias – LSIL, HSIL 85-90% SCC: begins in cells that line inner part of cervix connecting to vagina (ectocervix) meets opens into uterus (endocervix) transformation zone 10% Adenocarcinoma

Cervical Cancer Majority occur at squamocolumnar junction – transformation zone Cervical cancer: 2nd most common cancer in women worldwide3 4th most common in USA and Connecticut11 Regular screening = sustained reduction in cervical cancer incidence and mortality1,2 In 2009, there was an estimated 11,270 new cases of invasive cervical cancer, with an estimated 4,070 cancer-related deaths in the U.S.4 Highly curable when found and treated early

Risk of Cervical Cancer ALL WOMEN ARE AT RISK Not having regular Pap Smears Not following up with PCP on abnormal Pap results AIDS/HIV, immunocompromised Smoking Most Common age > 30 years old12 Main Cause  Human papillomavirus (HPV) Sexually transmitted infection Changes in cervical cells  cervical cancer, genital warts At least half of sexually active people will have HPV at some point in their lives. 6 out of 10 cervical cancers cases occur in women who have never received a Pap test or have not been tested in the past 5 years.13

The Papanicolaou (PAP) Smear Introduced in US in 1941 This test has been designed as a screening test to be administered to asymptomatic patients rather than as a diagnostic test. Many studies have shown that a failure of follow-up can lead to advanced cancers.5 Studies have also documented that follow-up for abnormal Papanicolaou tests showed fairly consistent findings that young age, minority race, lack of transportation and low socioeconomic status are risk factors for noncompliance with recommendations for diagnostic testing.6,7

Pap Screening Conventional PAP: cells sampled from cervix and vagina using brush/spatula  placed on slide  chemical fixative ThinPrep: slide uniformity, less chance of re-screen, cost effective

Federally Qualified Health Center (FQHC) look-alike 12,000 individuals in the Norwich community with integrated primary care, dental care and behavioral heath services Beginning August 2010, UCFS will provide obstetrics and gynecology services Fulfills one of the Health Resources and Services Administration (HRSA) Core Clinical Measures (CCMs) HRSA defined a set of evidence-based CCMs that targets high-priority health conditions found about populations defined as “safety-net” populations by the Institute of Medicine (IOM) requiring national action to improve the quality of health care.9 Achieving a CCM, will improve UCFS’s ability to become a FQHC and provide more competent and quality health care to its patients.

Current Tracking System

Goals & Objectives Objectives: Establish office protocol for tracking patients’ Pap smears and reminding them to keep recommended follow-up appointments. Communicate effectively with patients to explain Pap smear results, colposcopy procedure and importance of compliance with management plan. GOALS: Establish an updated policies and procedures: Pap Smear and Cervical Cancer Screening Guidelines Implement an electronic tracking system to help facilitate tracking until a full EMR is in place

Policies/Procedures (USTFPS and ACOG) Start age: 21 yrs old or 3 yrs after first sexual activity Every year until age 30: if had 3 consecutive normal exams  screened once every 3 years Stop age: 65 yrs old (3 consecutive normal exams or no abnormal exams in the past 10 years) No need to screen those who have had a total hysterectomy for non-cancerous reasons Participate in CT DPH Breast and Cervical Cancer Early detection Program. No insurance  Lawrence and Memorial Hospital case manager Breast exam, Pap smear and mammogram free of charge if qualify STD clinic at Backus Hospital if out of pocket expense is a concern.

Follow-up Treatment Given Abnormal Pap Smear Infection: Trichomonas, BV, Candida ASCUS LSIL, HSIL, ASC-H, AGC, AGC favor neoplasm + HPV – HPV Colposcopy Follow up in 3 to 4 months with repeat pap smear or proceed to colposcopy

Recommend HPV Vaccine Advisory Committee on Immunization Practices (ACIP) HPV2 (16, 18) and HPV4 (6, 11, 16, 18) Series of 3 shots (starting at 11 or 12 years old) Can start as early as 9years old Recommended: Boys and Girls between age 9 to 26

New Tracking System Microsoft Access in hopes it will better integrate with future EMR system

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